A nurse manager is performing a quality improvement assessment to determine the source of a recurrence of Clostridium difficile on a unit. The nurse manager should identify that which of the following nursing actions is a possible source of infection?

Wearing gloves when performing perineal care

Failing to don a mask when entering a client's isolation room

Cleansing visibly fecal-soiled hands with alcohol-based hand rub

Putting on a protective gown before entering a client's room

Answer and Explanation

The Correct Answer is C

Cleansing visibly fecal-soiled hands with alcohol-based hand rub is a possible source of infection because alcohol-based hand rubs are not effective against Clostridium difficile spores. The nurse should wash his or her hands with soap and water for at least 15 seconds after contact with fecal material or surfaces contaminated with feces.

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Correct Answer is B

Explanation

Recording output for a client who has multiple drains and tubes is a task that can be delegated to an AP, as it does not require nursing judgment or assessment skills. Reinserting an NG tube, teaching a family member how to change a dressing, and suctioning a tracheostomy are tasks that require nursing judgment, assessment skills, and specialized knowledge, and therefore cannot be delegated to an AP.

A. Secure the tracheostomy ties to allow one finger to fit snugly underneath. B. Soak the outer cannula in warm, soapy tap water. C. Use a cotton tip applicator to clean inside the inner cannula D. Cleanse the skin around the stoma with normal saline.

Correct Answer is A

Explanation

A tracheostomy is a surgical opening in the neck that allows air to enter the lungs through a tube called a tracheostomy tube. The tube has two parts: an outer cannula that stays in place and an inner cannula that can be removed for cleaning. The tracheostomy ties are used to secure the tube to the neck and prevent it from falling out. They should be adjusted to allow one finger to fit snugly underneath, so that they are not too tight or too loose.

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A nurse manager is performing a quality improvement assessment to determine the source of a recurrence of Clostridium difficile on a unit. The nurse manager should identify that which of the following nursing actions is a possible source of infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to delegate client care to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

Correct Answer is B

Explanation

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

A nurse is providing instruction to a client who has diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is agitated and threatening to harm others. The nurse places the client in restraints, but does not notify the provider or obtain a prescription for the restraints. This situation represents which of the following torts?

A nurse is caring for a client who is nauseated and unable to eat after taking an antibiotic. Identify the steps the nurse should take to address the client's nausea. (Move the steps into the box on the right, placing them in order of performance. Use all steps.)

A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?