A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?
Place the client in a protective environment.
Clean surfaces with chlorhexidine.
Wash hands with alcohol-based hand rub.
Obtain a stool specimen with gloves.
The Correct Answer is A
Clostridium difficile is a spore-forming bacteria that can cause severe diarrhea and other gastrointestinal symptoms. It's highly contagious and can easily spread to other patients. Alcohol-based hand rubs are not effective against spores and should not be used for hand hygiene in this case. Chlorhexidine is also not sporicidal and should not be used for environmental cleaning. A protective environment is indicated for clients who are at risk of infection from others, not for clients who are infectious to others. Gloves are important for preventing the spread of infection, but they should be used in conjunction with other infection control measures, such as handwashing and protective isolation.
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Correct Answer is D
Explanation
A mastectomy is a surgical removal of one or both breasts, usually done to treat breast cancer. The nurse should respect the client's autonomy and provide factual information about the procedure, its benefits and risks, and possible alternatives . The nurse should also assess the client's readiness to learn, address any concerns or fears, and offer emotional support . Telling the client to get a second opinion may imply that the nurse does not trust the surgeon or doubts the necessity of the procedure.
Telling the client that they will be cancer-free if they have the procedure may be false or misleading, as there may be residual cancer cells or recurrence after surgery. Giving the client a list of other people who had the same procedure may violate confidentiality and may not be helpful or relevant to the client's situation.
Correct Answer is A
Explanation
The nurse should hang the drainage bag below the level of the client's abdomen to facilitate gravity drainage of fluid and waste products from the peritoneal cavity. The other options are incorrect because they may cause discomfort, infection, or inadequate dialysis.
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