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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
The nurse should first palpate the abdomen to assess for signs of appendicitis, such as rebound tenderness, guarding, or rigidity. Appendicitis is a medical emergency that requires prompt diagnosis and treatment to prevent rupture and peritonitis.
Correct Answer is A
Explanation
A condom catheter is a urine collection device that fits like a condom over the penis and has a tube that goes to a collection bag strapped to the leg. To apply a condom catheter, the nurse should clean and dry the penis thoroughly, unroll the sheath over the penis, leaving 2.5 to 5 cm (1 to 2 in) of space between the end of the catheter and the tip ofthe penis, and gently squeeze the catheter around the penis shaft for 10 to 15 seconds to ensure adhesion.
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