A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which of the following actions should the nurse plan to take?
Use an alcohol-based agent to perform hand hygiene when caring for the client.
Obtain a blood specimen to test for C. difficile.
Place the client on contact precautions.
Place a surgical mask on the client during transport.
The Correct Answer is C
A. Alcohol-based hand sanitizers are not effective against C. difficile spores; hand hygiene should be performed using soap and water to effectively remove the spores.
B. Testing for C. difficile typically involves stool samples, not blood specimens, making this option inappropriate for confirming the infection.
C. Placing the client on contact precautions is essential to prevent the spread of C. difficile, as it is highly contagious and can be transmitted via surfaces and direct contact.
D. A surgical mask is not necessary for clients with C. difficile unless they have respiratory symptoms; the primary concern is preventing contact transmission.
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Correct Answer is C
Explanation
A. Verifying the client's room number is not a reliable method of identification, as multiple clients can be in the same room or the client may have been moved.
B. Checking the client's name on the MAR is a good practice but should be combined with a direct method of identification for accuracy.
C. Asking the client for their full name and date of birth is the standard practice for confirming identity before administering medications, ensuring that the nurse is addressing the correct individual.
D. Asking a family member to verify the client's identity is not appropriate, as the nurse must confirm the client's identity personally to maintain safety and accountability.
Correct Answer is C
Explanation
A. Giving the medication that is expired poses a risk to the client, as the safety and efficacy of the medication cannot be guaranteed past its expiration date.
B. Returning the medication to the pharmacy may not be feasible in this scenario; proper disposal is generally the nurse's responsibility for expired medications.
C. Discarding the medication is the appropriate action to ensure client safety, as expired medications should not be administered.
D. Notifying the provider is unnecessary in this case; the nurse's responsibility is to discard the expired medication and prepare a new dose that is within its expiration date.