A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others?
Clean hands with an alcohol-based hand rub immediately after removing gloves.
Remove the cover gown in the client's room after providing care.
Place the client in a room with negative-pressure airflow.
Wear a mask when administering oral medications to the client.
The Correct Answer is B
The correct answer is choice B. Remove the cover gown in the client’s room after providing care. This is because Clostridium difficile spores are not effectively killed by alcohol-based hand rubs and can survive on surfaces for a long time. Removing the gown in the client’s room helps to contain any spores that may have settled on the gown, preventing them from being spread to other areas.
Choice A rationale:
Cleaning hands with an alcohol-based hand rub immediately after removing gloves is wrong because C. difficile spores are resistant to alcohol-based hand rubs. The recommended practice is thorough handwashing with soap and water to physically remove the spores from the hands.
Choice C rationale:
Placing the client in a room with negative-pressure airflow is wrong because this measure is used for airborne infections, such as tuberculosis. C. difficile is spread via the fecal-oral route, primarily through contact with contaminated surfaces or hands, not through the air.
Choice D rationale:
Wearing a mask when administering oral medications to the client is wrong because C. difficile is not spread through respiratory droplets. Masks are not necessary unless there is a risk of splash or spray of contaminated material.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Use warm water when bathing the client.
Choice A rationale:
Using warm water when bathing helps maintain skin integrity by ensuring the skin is clean without causing excessive dryness or irritation. Warm water is gentle on the skin and helps in maintaining its natural moisture balance.
Choice B rationale:
Placing a donut-shaped cushion in the client’s chair is not recommended as it can cause pressure points and restrict blood flow, potentially leading to pressure ulcers.
Choice C rationale:
Massaging reddened areas over bony prominences is not advisable because it can cause further damage to already compromised skin and increase the risk of pressure ulcers.
Choice D rationale:
Maintaining the client in high-Fowler’s position for extended periods can increase pressure on the sacral area, leading to pressure ulcers. It is important to regularly reposition the client to alleviate pressure.
Correct Answer is C
Explanation
The correct answer is choice C: "I should remove constrictive clothing prior to measuring my blood pressure."
Choice A rationale:
"I will wait 15 minutes after drinking coffee to measure my blood pressure." Caffeine intake can temporarily elevate blood pressure, so waiting 15 minutes after drinking coffee is a good practice. However, this is not the most relevant instruction to ensure accurate blood pressure measurement.
Choice B rationale:
"I will measure my blood pressure while my arm is elevated above my heart." Measuring blood pressure with the arm elevated above the heart can result in artificially low readings. The arm should be supported at heart level for accurate results. Therefore, this statement is incorrect.
Choice C rationale:
"I should remove constrictive clothing prior to measuring my blood pressure." This is the correct choice. Constrictive clothing can impact blood flow and give inaccurate readings. Removing tight clothing ensures the blood pressure cuff can be appropriately placed and that the measurements are reliable.
Choice D rationale:
"I should measure my blood pressure immediately after eating breakfast." Blood pressure can be affected by food intake, so it's recommended to wait at least 30 minutes after eating before measuring blood pressure. This choice is not accurate as immediate post-breakfast measurements may not provide accurate results.
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