The nurse is caring for a patient with Clostridium difficile. Which nursing actions will have the greatest impact in preventing the spread of the bacteria?
a. Appropriate disposal of contaminated items in biohazard bags
b. Monthly in-services about contact precautions
c. Mandatory cultures on all patients
d. Proper hand hygiene techniques
ANS: D
Proper hand hygiene is the best way to prevent the spread of bacteria. Soap and water are mandatory. Monthly in-services place emphasis on education, not on action. Biohazard bags are appropriate but cannot be used on every item that C. difficile comes in contact with, such as a human. Mandatory cultures are expensive and unnecessary and would not prevent the spread of bacteria.
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The nurse will instruct patients about a
possible systemic effect that may occur if excessive amounts of topically applied adrenergic nasal decongestants are used. Which systemic effect may occur? a. Heartburn b. Bradycardia c. Drowsiness d. Palpitations
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A) A yes/no question B) A directing question C) An open-ended question D) A reflective question
Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. The nurse should follow up by asking
a. "When was the last time you voided?" b. "Do you lose urine when you cough or sneeze?" c. "Have you noticed any change in your urination patterns?" d. "Do you have a fever or chills?"