nurse is caring for a client who has Clostridium difficile (C. difficile). Which of the following actions should the nurse take?

Clean hands with soap and water after caring for the client

Place the client in a room with negative pressure airflow

Wash hands for 10 seconds after caring for the client

Apply a mask on the client when they are outside their room

Answer and Explanation

The Correct Answer is A

A. Clean hands with soap and water after caring for the client: C. difficile spores are resistant to alcohol-based hand sanitizers. Therefore, it is essential to use soap and water to effectively remove the spores from hands.
B. Place the client in a room with negative pressure airflow: C. difficile is not an airborne infection, so negative pressure airflow is not required. This measure is typically used for infections such as tuberculosis.
C. Wash hands for 10 seconds after caring for the client: Handwashing with soap and water should be done for at least 20 seconds to effectively remove C. difficile spores.
D. Apply a mask on the client when they are outside their room: A mask is not necessary for clients with C. difficile, as the infection is not transmitted through respiratory droplets but rather through fecal-oral transmission.

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Correct Answer is ["A","D"]

Explanation

A. Provide educational material written at an eighth-grade reading level: Educational material should be understandable to the client, and an eighth-grade reading level is typically accessible for most individuals.
B. Turn on the television in the client's room: Turning on the television can be distracting and is not conducive to effective preoperative teaching.
C. Use technical language in the educational session: Technical language can be confusing for clients; plain language should be used to ensure understanding.
D. Start with the most important information: Prioritizing the most critical information ensures that the client understands essential aspects of their procedure, even if they cannot retain all details.

A. Use a square knot. B. Assess the extremity for circulation and neurological integrity every 2 hours. C. Secure the restraint to the side rail. D. Assess restraints and skin integrity every 12 hours.

Correct Answer is B

Explanation

A. Use a square knot. Using a square knot is not recommended for securing restraints because it can be difficult to quickly release in an emergency. Instead, restraints should be secured with a quick-release tie to ensure they can be removed promptly if necessary.
B. Assess the extremity for circulation and neurological integrity every 2 hours. Regular assessment of the extremity is essential to ensure that the restraint is not impairing circulation or causing nerve damage. This frequent monitoring helps prevent complications and ensures the client’s safety.
C. Secure the restraint to the side rail. Securing restraints to the side rail is not recommended as it can cause injury or entrapment. The restraint should be secured to the bed frame or a fixed part of the bed that does not move or pose a risk to the client.
D. Assess restraints and skin integrity every 12 hours. Assessing restraints and skin integrity every 12 hours is inadequate. More frequent assessments, such as every 2 hours, are necessary to prevent skin breakdown and ensure that the restraints are not causing harm.

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nurse is caring for a client who has Clostridium difficile (C. difficile). Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to provide preoperative teaching for a client. Which of the following actions should the nurse plan to take?

Correct Answer is ["A","D"]

Explanation

Which of the following is essential when restraints are applied to a client?

Correct Answer is B

Explanation

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