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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.
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A client has a prescription for a 24-hour urine collection. Which of the following actions should the nurse take?
- A. Discard the first voiding.
- B. Keep the urine in a single container on ice.
- C. Include the last voiding in the collection.
- D. Instruct the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.
Correct Answer: A
Rationale: The correct action for the nurse to take when a client has a prescription for a 24-hour urine collection is to discard the first voiding. This initial voiding is typically not collected to allow for the accurate start of the 24-hour collection period. All subsequent urine voided within the specified time frame is then collected. Including the last voiding in the collection is important to ensure that the full 24-hour period is covered. It is essential to keep the urine cool by storing it in a single container on ice to prevent degradation of components. Instructing the client to stop midstream and finish urinating into the specimen container is not required for a 24-hour urine collection and is an unnecessary step.
A healthcare professional is preparing to perform a sterile dressing change for a client. Which of the following actions should the healthcare professional plan to take?
- A. Don sterile gloves after opening sterile dressing supplies
- B. Set up the sterile field at waist level
- C. Consider the entire border of the sterile field as contaminated
- D. Place the cap of a sterile solution inside the sterile field
Correct Answer: B
Rationale: Setting up the sterile field at waist level is crucial to maintaining its sterility during a dressing change. Choice A is incorrect because sterile gloves should be worn after opening sterile dressing supplies to prevent contamination. Choice C is incorrect as the entire border of the sterile field should be considered contaminated to maintain sterility. Choice D is incorrect because the cap of a sterile solution should never be placed inside the sterile field to prevent contamination.
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.
During passive range of motion (ROM) exercises, how should the nurse perform each movement for a patient with impaired mobility?
- A. The nurse moves each movement just to the point of resistance.
- B. The patient repeats each movement 5 times.
- C. The movement continues until the patient reports pain.
- D. The nurse completes each movement quickly and smoothly.
Correct Answer: A
Rationale: During passive range of motion (ROM) exercises, the nurse is responsible for moving the patient's joints through their range of motion. The correct technique involves performing movements slowly and smoothly, only going to the point of resistance without causing pain. This technique helps maintain joint flexibility and prevent contractures. Choice A is the correct answer as it reflects the appropriate technique for passive ROM exercises. Choices B and C are incorrect because the patient is not actively participating, and ROM exercises should not cause pain. Choice D is incorrect as movements should be done deliberately and not quickly.
A client receives the influenza vaccine in a clinic. Within 15 minutes after the immunization, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. What should be the first action in the sequence of care for this client?
- A. Maintain the airway
- B. Administer epinephrine 1:1000 as ordered
- C. Monitor for hypotension with shock
- D. Administer diphenhydramine as ordered
Correct Answer: B
Rationale: In the scenario described, the client is experiencing symptoms of an anaphylactic reaction, a severe allergic response. The priority action in an anaphylactic reaction is to administer epinephrine. Epinephrine helps counteract the severe allergic response, improves breathing difficulties, and maintains airway and circulation. Administering epinephrine takes precedence to stabilize the client's condition. Options A, C, and D may be necessary in the management of anaphylaxis, but the immediate priority is to administer epinephrine to address the life-threatening symptoms.