Nokea
A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?
- A. Assign the client to a room with a negative air-flow system.
- B. Use alcohol-based hand sanitizer when leaving the client's room.
- C. Clean contaminated surfaces in the client's room with a phenol solution.
- D. Have family members wear a gown and gloves when visiting.
Correct Answer: D
Rationale: When caring for clients with Clostridium difficile infection, it is important to prevent the transmission of spores. Having family members wear a gown and gloves when visiting helps reduce the spread of the infection. Choices A, B, and C are incorrect because assigning the client to a room with a negative air-flow system, using alcohol-based hand sanitizer, and cleaning surfaces with a phenol solution are not specific measures targeted at preventing the transmission of Clostridium difficile spores.
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While observing a student nurse administering a narcotic analgesic IM injection without aspirating, what should the nurse do?
- A. Ask the student, 'What did you forget to do?'
- B. Stop and explain why aspiration is needed.
- C. Quietly state, 'You forgot to aspirate.'
- D. Walk up and whisper in the student's ear, 'Stop. Aspirate. Then inject.'
Correct Answer: D
Rationale: When the nurse observes a student nurse making a mistake during a procedure, such as not aspirating before administering a medication, the nurse should provide immediate, discreet feedback to correct the error. Walking up and whispering in the student's ear to stop, aspirate, and then inject is appropriate as it corrects the mistake while maintaining the student's dignity and confidence. Option A is not as effective as it indirectly addresses the issue. Option B is not the best approach as the student needs immediate correction. Option C is not ideal as loudly stating the mistake may embarrass the student and is not necessary for a discreet correction.
When using an open irrigation technique for a client's catheter, what action should the nurse take?
- A. Subtract the amount of irrigant used from the client's urine output.
- B. Add the amount of irrigant used to the urine output measurement.
- C. Measure the amount of irrigant used separately from the urine output.
- D. Document the total amount of fluid used for irrigation only.
Correct Answer: A
Rationale: The correct action for the nurse to take when using an open irrigation technique for a client's catheter is to subtract the amount of irrigant used from the client's urine output. This subtraction helps accurately assess the client's output by accounting for the volume of irrigant introduced. Choice B is incorrect because adding the irrigant to the urine output measurement would falsely inflate the total output, leading to inaccurate assessment. Choice C is incorrect as measuring the amount of irrigant separately does not provide an accurate assessment of the client's total output as it disregards the irrigant's contribution. Choice D is incorrect as documenting the total fluid used for irrigation only does not differentiate between the irrigant and the client's actual urine output, which is crucial for accurate monitoring and assessment.
A client's readiness to learn about insulin administration is being assessed by a nurse. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
- A. ''I can concentrate best in the morning.''
- B. ''It is difficult to read the instructions because my glasses are at home.''
- C. ''I'm wondering why I need to learn this.''
- D. ''You will have to talk to my wife about this.''
Correct Answer: A
Rationale: Choice A is the correct answer because the client's statement about the best time to concentrate indicates readiness for learning. This statement shows an awareness and interest in learning. Choice B is incorrect as it indicates a barrier to learning due to not having glasses. Choice C is incorrect as it shows a lack of understanding or motivation for learning. Choice D is incorrect as it suggests a lack of personal involvement or responsibility in the learning process since the client is deflecting the responsibility to someone else.
A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client?
- A. "Get up and change positions slowly."
- B. "Avoid eating aged cheese and smoked meat."
- C. "Report any unusual bruising or bleeding to the doctor immediately."
- D. "Eat the same amount of foods that contain vitamin K every day."
Correct Answer: A
Rationale: The correct instruction for the nurse to give the client who is starting on antihypertensive medication is to 'Get up and change positions slowly.' Antihypertensive medications can cause orthostatic hypotension, a drop in blood pressure when changing positions, so changing positions slowly helps prevent this adverse effect. Choice B about avoiding aged cheese and smoked meat is more relevant for clients taking monoamine oxidase inhibitors (MAOIs) due to potential interactions. Choice C regarding reporting unusual bruising or bleeding is more applicable for clients on anticoagulants. Choice D about consuming consistent amounts of vitamin K-containing foods daily is important for clients taking warfarin, not antihypertensive medications.
A client has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?
- A. Wear gloves when changing the client's gown.
- B. Use hand sanitizer after contact with the client.
- C. Wear a mask when entering the client's room.
- D. Clean the room with a disinfectant spray.
Correct Answer: A
Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile in contact isolation is to wear gloves when changing the client's gown. Clostridium difficile is highly transmissible, and wearing gloves helps prevent the spread of the infection. Using hand sanitizer after contact with the client (Choice B) is not enough to prevent the transmission of C. difficile, as the spores can persist and spread. Wearing a mask when entering the client's room (Choice C) is not necessary for C. difficile transmission, which primarily occurs through contact with contaminated surfaces. Cleaning the room with a disinfectant spray (Choice D) is important, but wearing gloves during direct care is the priority to prevent the nurse from acquiring and spreading the infection.