While changing the dressing of a client who is immobile, the practical nurse (PN) observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor.

Before reporting this finding to the healthcare provider, the PN should evaluate which of the client's laboratory values?

Choice A rationale:

The risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.

Choice B rationale:

Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.

Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.

Choice C rationale:

Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.

Choice D rationale:

Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.

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.