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 A

Explanation

The nurse should explain the need to have another adult drive the client home following surgery, as this is a safety measure to prevent complications such as bleeding, infection, or injury due to impaired cognition or mobility after anesthesia or sedation. The nurse should ask the client to shower once with an antiseptic soap on either the night before or morning of surgery, not 3 times the day before surgery, as this can reduce the risk of surgical site infection. The nurse should inform the client that they cannot wear makeup during surgery, as this can interfere with the monitoring of skin color and oxygen saturation. The nurse should instruct the client to stop drinking clear liquids at least 2 hours before surgery, not 1 hour before surgery, as this can reduce the risk of aspiration and gastric distension.

A. Administer acetaminophen to the client. B. Complete an incident report C. Document the occurrence in the client's medical record. D. Send the visitor to the risk management office.

Correct Answer is B

Explanation

A nursing incident report is a document that provides detailed information and account of the chain of events leading up to and following an unforeseen circumstance in a healthcare setting or facility especially in the nursing side. An incident report is used to communicate important safety information to hospital administrators and keep them updated on aspects of patient care for risk management, quality assurance, educational, and legal purposes. An incident report should be completed within 24 hours by whomever witnessed the incident or was notified first. In this case, the nurse should complete an incident report because the visitor's fall is an unforeseen circumstance that threatens patient safety and could have legal implications.

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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 providing preoperative teaching to a client over the phone in preparation for outpatient surgery. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

A visitor reports to a nurse that she slipped and fell in a client's room. The visitor denies any injury, but is walking with a slight limp. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is preparing to administer several medications to a client. Which of the following data should the nurse plan to use to confirm the client's identity?

A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take?

A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

A nurse hangs a bag of dextrose 5% in water 1,000 mL at 0800 to run at 125 mL/hr. At 1200, the nurse notices that the client's IV bag is empty. Which of the following interventions should the nurse take first?

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 on a medical-surgical unit is caring for a client who reports difficulty sleeping at night. Which of the following findings should indicate to the nurse that the client has sleep deprivation?

A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?