A nurse is serving on a committee that is developing infectious disease protocols. Which of the following instructions should the nurse include in the protocol for clients who have Clostridium difficile?

Disinfect hands using an alcohol-based waterless antiseptic.

Wear an N95 respirator when caring for the client.

Use diluted bleach to clean solled equipment.

Provide a room with negative-pressure airflow.

Answer and Explanation

The Correct Answer is C

A. Disinfecting hands using an alcohol-based waterless antiseptic is not effective against Clostridium difficile spores. C. difficile is a bacterium that forms spores, which are resistant to alcohol-based hand sanitizers. Handwashing with soap and water is recommended for effective removal of the spores.

B. Wearing an N95 respirator is not specifically indicated for caring for clients with Clostridium difficile. The primary mode of transmission for C. difficile is fecal-oral, and standard precautions, including gloves and gowns, are usually sufficient. N95 respirators are more commonly used for airborne precautions.

C. Using diluted bleach to clean soiled equipment is the correct instruction. Clostridium difficile spores are resistant to many disinfectants, but bleach (sodium hypochlorite) is effective in killing C. difficile spores. Diluted bleach solutions are recommended for cleaning surfaces and equipment that may be contaminated with C. difficile.

D. Providing a room with negative-pressure airflow is not typically necessary for clients with Clostridium difficile. Standard precautions, including appropriate cleaning and disinfection, are generally sufficient to prevent the spread of C. difficile in healthcare settings.

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Correct Answer is B

Explanation

A. Completing an incident report is an important step to document the error, but the immediate priority is to assess the client's condition and address any potential adverse effects. Incident reporting can follow once the immediate assessment and interventions are completed.

B. Checking the client's vital signs is the first action to take. The nurse needs to assess the client's physiological response to the double dose, as some medications can have significant effects on vital signs. Monitoring vital signs provides crucial information to determine the client's stability and whether additional interventions are needed.

C. Notifying the charge nurse of the error is an important step, but checking the client's vital signs takes precedence to ensure the client's immediate safety. The charge nurse can be informed after the initial assessment.

D. Documenting the facts of the incident in the nurse's notes is important, but it comes after assessing the client and taking immediate actions to address any potential harm. Documenting the incident helps maintain a comprehensive record and contributes to the overall understanding of the event.

A. Ask the APs to discontinue the conversation. B. Inform the client what has occurred. C. Notify the client's provider. D. Schedule a disciplinary conference for the APS.

Correct Answer is A

Explanation

Ask the APs to discontinue the conversation:

This is the most appropriate immediate action. Discussing a client's care in a public area violates the principle of patient confidentiality. The nurse should intervene promptly and ask the assistive personnel to stop the conversation.

Inform the client what has occurred:

While transparency with the client is important, it may not be the first action to take in this situation. The priority is to address the breach of confidentiality by stopping the conversation.

Notify the client's provider:

Notifying the client's provider is not the initial action to take in this situation. First, the nurse should address the immediate issue by stopping the inappropriate conversation. The provider may be informed later, if necessary.

Schedule a disciplinary conference for the APs:

Scheduling a disciplinary conference is a step that may be taken after addressing the immediate issue. The priority is to stop the inappropriate conversation and address confidentiality concerns before considering disciplinary actions.

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A nurse is serving on a committee that is developing infectious disease protocols. Which of the following instructions should the nurse include in the protocol for clients who have Clostridium difficile?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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