Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is disinfecting the room of a client who has a Clostridium difficultiesinfection. Which of the following solutions should the nurse use?
A. Chlorhexidine.
is wrong because chlorhexidine is not effective against C. difficile spores.
B. Isopropyl alcohol.
B is wrong because isopropyl alcohol is also not effective against C. difficile spores.
C. Chlorine bleach.
According to the CDC1, chlorine bleach is an effective disinfectant for killing C. difficile spores on environmental surfaces. It should be used in a 1:10 dilution of household bleach and water, freshly mixed daily. Chlorine bleach can also kill other pathogens that may be present in the room of a client with C. difficile infection
D. Triclosan.
wrong because triclosan is a type of antibacterial agent that is commonly found in some consumer products, such as soap and toothpaste. However, triclosan has no activity against it. Triclosan may also contribute to antibiotic resistance and has potential adverse effects on human health and the environment.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Fundamentals 2020 with NGN Proctored Exam. Take the full exam now
Full Explanation
According to the CDC1, chlorine bleach is an effective disinfectant for killing C. difficile spores on environmental surfaces.
It should be used in a 1:10 dilution of household bleach and water, freshly mixed daily.
Chlorine bleach can also kill other pathogens that may be present in the room of a client with C. difficile infection.
Choice A is wrong because chlorhexidine is not effective against C. difficile spores.
Chlorhexidine is an antiseptic that can be used for hand hygiene and surgical asepsis, but it does not kill spores.
Choice B is wrong because isopropyl alcohol is also not effective against C. difficile spores.
Alcohol-based hand sanitizers are not sufficient for preventing the spread of C. difficile, and soap and water should be used instead.
Choice D is wrong because triclosan is a type of antibacterial agent that is commonly found in some consumer products, such as soap and toothpaste. However, triclosan has no activity against C. difficile spores.
Triclosan may also contribute to antibiotic resistance and has potential adverse effects on human health and the environment.
Similar Questions
A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit.
Which of the following actions should the nurse include in the plan?
A. Offer the clients many choices regarding care.
Choice A is wrong because offering the clients many choices regarding care can increase their stress and anxiety, especially if they are confused, overwhelmed, or unable to make decisions. The nurse should respect the client’s autonomy and preferences, but also provide guidance and education to help them make informed choices.
B. Restrict the number of visitors for clients.
This action can help to reduce environmental stressors for clients in an acute care unit by limiting noise, crowding, and potential sources of infection.
C. Assign different nurses to provide care for clients each day.
Choice C is wrong because assigning different nurses to provide care for clients each day can reduce the continuity and quality of care, as well as the trust and rapport between the client and the nurse. The nurse should strive to provide consistent and individualized care for each client and establish a therapeutic relationship.
D. Turn on loud music in client care areas.
Choice D is wrong because turning on loud music in client care areas can increase environmental stressors for clients in an acute care unit by creating noise pollution, disrupting sleep, and interfering with communication. The nurse should maintain a quiet and calm environment for the clients and use music only if it is soothing and requested by the client.
Full Explanation
This action can help to reduce environmental stressors for clients in an acute care unit by limiting noise, crowding, and potential sources of infection.
Visitors should be allowed according to the client’s preference and condition, but excessive or inappropriate visitors should be discouraged.
Choice A is wrong because offering the clients many choices regarding care can increase their stress and anxiety, especially if they are confused, overwhelmed, or unable to make decisions.
The nurse should respect the client’s autonomy and preferences, but also provide guidance and education to help them make informed choices.
Choice C is wrong because assigning different nurses to provide care for clients each day can reduce the continuity and quality of care, as well as the trust and rapport between the client and the nurse.
The nurse should strive to provide consistent and individualized care for each client and establish a therapeutic relationship.
Choice D is wrong because turning on loud music in client care areas can increase environmental stressors for clients in an acute care unit by creating noise pollution, disrupting sleep, and interfering with communication.
The nurse should maintain a quiet and calm environment for the clients and use music only if it is soothing and requested by the client.
A nurse is caring for a client who is postoperative and is preparing to walk for the first time in several days.
Which of the following instructions should the nurse give the client to prevent orthostatic hypotension?
A. “Perform regular isometric exercises.”.
Choice A is wrong because “Perform regular isometric exercises.” Isometric exercises are muscle contractions without movement, such as squeezing a ball or clenching a fist. These exercises do not help with orthostatic hypotension because they do not improve blood circulation or blood pressure.
B. “Increase your intake of protein.”.
Choice B is wrong because “Increase your intake of protein.” Protein intake does not affect orthostatic hypotension directly. However, staying hydrated by drinking plenty of fluids can help prevent or manage the condition by maintaining blood volume and blood pressure.
C. “Dangle your legs over the side of the bed.”.
The correct answer is choice C. “Dangle your legs over the side of the bed.” This helps prevent orthostatic hypotension, which is a form of low blood pressure that happens when standing after sitting or lying down.
D. “Use your incentive spirometer.”.
Choice D is wrong because “Use your incentive spirometer.” An incentive spirometer is a device that helps improve lung function after surgery by encouraging deep breathing. It does not prevent orthostatic hypotension because it does not affect blood pressure or blood flow.
Full Explanation
The correct answer is choice C. “Dangle your legs over the side of the bed.” This helps prevent orthostatic hypotension, which is a form of low blood pressure that happens when standing after sitting or lying down.
Dangling the legs over the side of the bed allows blood to flow back to the heart and increases blood pressure before standing up.
Choice A is wrong because “Perform regular isometric exercises.” Isometric exercises are muscle contractions without movement, such as squeezing a ball or clenching a fist.
These exercises do not help with orthostatic hypotension because they do not improve blood circulation or blood pressure.
Choice B is wrong because “Increase your intake of protein.” Protein intake does not affect orthostatic hypotension directly.
However, staying hydrated by drinking plenty of fluids can help prevent or manage the condition by maintaining blood volume and blood pressure.
Choice D is wrong because “Use your incentive spirometer.” An incentive spirometer is a device that helps improve lung function after surgery by encouraging deep breathing.
It does not prevent orthostatic hypotension because it does not affect blood pressure or blood flow.
A nurse is reinforcing teaching with the adult children of a client who is receiving palliative care.
Which of the following statements by one of the adult children indicates an understanding of the teaching?
A. “We won’t allow her spiritual advisor to visit during this time.”.
Choice A is wrong because it contradicts the goal of palliative care to address the spiritual needs of the patients and their families. Spiritual advisors can help patients cope with their illness and find meaning and purpose in their situation.
B. “We will receive emotional support during our mother’s illness.”.
The correct answer is choice B. Palliative care is a type of care that improves the quality of life of patients and their families who are facing problems associated with life-threatening illness.
C. “We won’t discuss the illness in the presence of our mother.”.
Choice C is wrong because it denies the patient the opportunity to express their feelings and concerns about their illness. Palliative care involves open and honest communication between the patients, their families and the health care team. Discussing the illness can help patients make informed decisions about their care and prepare for the end of life.
D. “We will provide resuscitation to our mother if necessary.”.
Choice D is wrong because it goes against the principle of palliative care to respect the patient’s wishes and preferences regarding their treatment. Resuscitation is a procedure that attempts to revive someone from apparent death or unconsciousness. Some patients may not want resuscitation if they have a terminal illness or a poor quality of life. They may have an advance directive or a living will that states their preferences for end-of-life care.
Full Explanation
The correct answer is choice B. Palliative care is a type of care that improves the quality of life of patients and their families who are facing problems associated with life-threatening illness.
It prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual.
Palliative care also provides emotional support to the patients and their families during the illness.
Therefore, choice B indicates an understanding of the teaching.
Choice A is wrong because it contradicts the goal of palliative care to address the spiritual needs of the patients and their families.
Spiritual advisors can help patients cope with their illness and find meaning and purpose in their situation.
Choice C is wrong because it denies the patient the opportunity to express their feelings and concerns about their illness.
Palliative care involves open and honest communication between the patients, their families and the health care team.
Discussing the illness can help patients make informed decisions about their care and prepare for the end of life.
Choice D is wrong because it goes against the principle of palliative care to respect the patient’s wishes and preferences regarding their treatment.
Resuscitation is a procedure that attempts to revive someone from apparent death or unconsciousness.
Some patients may not want resuscitation if they have a terminal illness or a poor quality of life.
They may have an advance directive or a living will that states their preferences for end-of-life care.