The practical nurse (PN) observes a client’s initial postoperative dressing, which is saturated with serosanguinous fluid, and a drainage device that appears partially compressed. Which follow-up actions should the PN implement? (Select all that apply.).

The correct answer is choiceB. Verify completion of all new prescriptions. This task is crucial to ensure patient safety and proper medication administration.

Choice A rationale:

Clean up and organize the nurses’ workstation: While maintaining an organized workstation is important for efficiency and reducing stress, it is not the highest priority task. Patient safety and care tasks take precedence over organizational tasks.

Choice B rationale:

Verify completion of all new prescriptions: This is the highest priority because verifying new prescriptions ensures that patients receive the correct medications as prescribed by their healthcare providers.This step is critical to prevent medication errors, which can have serious or even fatal consequences. Ensuring the accuracy of medication orders directly impacts patient safety and care quality.

Choice C rationale:

Calculate and record intake and output totals: Monitoring and recording intake and output is important for assessing a patient’s fluid balance and overall health status. However, this task can be delegated to another team member and does not take precedence over verifying medication orders, which is more time-sensitive and directly related to patient safety.

Choice D rationale:

Write a narrative shift summary for each client: Documenting a shift summary is essential for continuity of care and communication between healthcare providers. However, this task can be completed after ensuring that all critical patient care tasks, such as verifying new prescriptions, are addressed first.

The correct answer is choice D. Don non-sterile gloves when performing direct care.

Choice A rationale:

Placing a surgical mask on the client during transport is not necessary for preventing the spread of Clostridium difficile. C. difficile is primarily spread through contact with contaminated surfaces and not through airborne transmission.

Choice B rationale:

Keeping the door closed to the client’s room at all times is not required for C. difficile infection. The focus should be on contact precautions rather than airborne precautions.

Choice C rationale:

Wearing a particulate respirator mask is not needed for C. difficile, as it is not an airborne pathogen. Standard contact precautions are sufficient.

Choice D rationale:

Donning non-sterile gloves when performing direct care is essential to prevent the spread of C. difficile. The spores can be transmitted via the hands of healthcare workers, so wearing gloves helps to minimize this risk.