A nurse is performing Weber's test for a client who has hearing loss. Which of the following actions should the nurse take?

Rationale for Correct Choices:

• Oxygen saturation: The client's oxygen saturation has dropped to 90%, which is below the acceptable range of 92-100% for postoperative patients. This decrease in oxygen saturation needs immediate attention as it could indicate respiratory compromise or early signs of hypoxia.
• Behavioral findings: The client expresses a feeling of "something is wrong" and appears agitated, which may signal a complication, such as pain, anxiety, or more serious issues like internal bleeding or a developing embolism. The nurse should address the client's behavioral findings promptly to identify the cause.

Rationale for Incorrect Choices:

• Pain: The client rates incisional pain as 5 out of 10, which is moderate but not critical. While pain management is important, it is not the primary concern in this case given the client’s symptoms of agitation and decreased oxygen saturation.
• WBC count: The WBC count is mildly elevated (10,800/mm³), which could indicate a mild inflammatory response, possibly due to surgery. However, it is not as urgent as addressing the drop in oxygen saturation and the client’s behavioral changes.
• Bowel findings: Hypoactive bowel sounds are expected following abdominal surgery and are not immediately concerning. The client’s bowel status does not require urgent follow-up compared to their oxygen saturation and behavioral symptoms.

A. Provide a mask for the client when they are outside their room: The client has a positive influenza test, it is important to prevent the spread of the virus to others by wearing a mask when outside their room to minimize the risk of transmission through respiratory droplets.

B. Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room. While hand sanitizer is appropriate for influenza, droplet precautions, the client also has Clostridium difficile, which requires contact precautions, specifically hand hygiene with soap and water. Alcohol-based hand sanitizers are not effective against C. diff spores.

C. Don a gown when entering the client's room: The client is positive for C. difficile, which requires contact precautions. Wearing a gown when entering the room is necessary to protect healthcare workers from coming into contact with potentially contaminated surfaces or materials.

D. When removing personal protective equipment, remove gloves first: When removing personal protective equipment gloves should be removed first to avoid contamination of other surfaces. This is the recommended sequence for safe removal of PPE in contact precautions.

E. Place the client in a room with positive air flow: A room with positive air flow is necessary for airborne precautions (e.g., for tuberculosis or varicella), but it is not required for C. difficile or influenza, which are both managed through contact and droplet precautions.