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

Cheyne-Stokes respirations are an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes. This type of breathing may occur in people who are dying due to heart failure, stroke, brain injury or other causes. The nurse should expect to observe irregular respirations with frequent periods of apnea in the client who is dying and having Cheyne-Stokes respirations.

A. Take a 30-min nap daily. B. Exercise 1 hr before bedtime. C. Drink a cup of hot cocoa before bedtime D. Eat a light carbohydrate snack before bedtime.

Correct Answer is D

Explanation

This intervention can help promote sleep by increasing serotonin levels in the brain, which have a calming effect. The other interventions are not appropriate for a client who has insomnia.

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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 caring for a client who is dying and having Cheyne-Stokes respirations. Which of the following respiratory findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?

Correct Answer is D

Explanation

A nurse is providing end-of-life care for a client. Which of the following actions should the nurse take?

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 planning care for a client who is scheduled for an intravenous pyelogram (IVP). Which of the following actions is appropriate for the nurse to include?

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 is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?

A nurse in an acute care facility is preparing to transfer a client to a long-term care facility. Which of the following information should the nurse include in the hand-off report?

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?

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