A nurse is planning care for a client who has contact precautions in place. Which of the following actions should the nurse plan to take when removing soiled linens from the client's room?

Double-bag the linens.

Rinse the linens prior to removing them from the client's room.

Tie the linens' bag securely at the top.

Wear sterile gloves when handling the linens.

Answer and Explanation

The Correct Answer is A

A. Double-bag the linens: When a client is on contact precautions, it is necessary to place soiled linens in a sealed bag to prevent contamination. Double-bagging the linens ensures that the exterior bag does not become contaminated and that the linens are securely contained.

B. Rinse the linens prior to removing them from the client's room: Rinsing the linens is not required when removing soiled linens. The main concern is preventing contamination, and double-bagging ensures that the linens are safely contained.

C. Tie the linens' bag securely at the top: While it is important to securely close the bag, double-bagging is the key step in preventing contamination. Tying the bag is part of the process, but it is not the primary focus for contact precautions.

D. Wear sterile gloves when handling the linens: Sterile gloves are not necessary for handling soiled linens in contact precautions. Clean gloves are sufficient to handle linens. Sterile gloves are typically used for invasive procedures, not for routine linen handling.

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Correct Answer is A

Explanation

A. The client reports frequently having a headache in the morning: Frequent morning headaches can indicate sleep-related issues such as sleep apnea or bruxism (teeth grinding), both of which can significantly affect sleep quality and overall health.

B. The client reports having vivid dreams about their childhood: Vivid dreams can occur naturally, especially during rapid eye movement (REM) sleep. Although they may be unusual, they are not typically a cause for concern.

C. The client reports taking 30 min to fall asleep on average: Taking up to 30 minutes to fall asleep is within normal limits for most people. This is not a concerning finding and does not necessarily require reporting unless the client is experiencing other sleep disturbances.

D. The client reports sleeping about 7 hr on average: Sleeping around 7 hours per night is considered within the normal range for most adults. This is generally adequate sleep, and there is no indication of a significant issue that would require reporting to the provider.

A. Provide a mask for the client when they are outside their room. B. Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room. C. Don a gown when entering the client's room. D. When removing personal protective equipment, remove gloves first. E. Place the client in a room with positive air flow.

Correct Answer is ["A","C","D"]

Explanation

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.

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A nurse is planning care for a client who has contact precautions in place. Which of the following actions should the nurse plan to take when removing soiled linens from the client's room?

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