Question

Difficulty: MediumStandard and Transmission-Based Precautions

An individual with a severe Clostridioides difficile (C. diff) infection is admitted to an acute care medical unit. The practical nurse is assigned to participate in the client's care. Which of the following interventions should the nurse implement? Select all that apply.

  1. Put on a fluid-resistant gown and then clean gloves before entering the client's room.Answer
  2. Keep dedicated reusable medical equipment, such as a stethoscope, inside the client's room.Answer
  3. C
    Remove the contaminated gown in the unit hallway immediately after exiting the client's room.
  4. Perform hand hygiene using soap and water after removing personal protective equipment.Answer
  5. E
    Assign the unlicensed assistive personnel (UAP) to evaluate the client's skin turgor and hydration status.
  6. F
    Remove the fluid-resistant gown first, followed by the face mask, and finally the soiled gloves.

Answer

The correct interventions are to don a gown and gloves before entering the room, leave dedicated medical equipment inside the room, and wash hands with soap and water after removing protective equipment.
Appropriate contact precautions for C. diff involve donning a gown and gloves before entry, designating reusable equipment to remain in the room, and washing hands with soap and water because the spores are resistant to alcohol-based sanitizers. These actions successfully contain the pathogen and protect both the nurse and other clients.

Step-by-Step Solution

1
Identify the transmission-based precautions required for Clostridioides difficile.
The client requires contact precautions.
C. diff is transmitted via the fecal-oral route through spores, necessitating strict physical barriers.
2
Determine the appropriate donning sequence, doffing location, and hand hygiene method.
Gown and gloves must be donned prior to entry and doffed inside the room; hand hygiene must be performed with soap and water.
PPE must be removed in the room to contain pathogens, and alcohol-based rubs are ineffective against C. diff spores.
3
Evaluate the proposed delegation action against the licensed practical nurse's scope of practice.
Delegating the evaluation of hydration status is incorrect.
Unlicensed assistive personnel cannot perform clinical assessments or evaluate a client's physical status.

Key Concept

Contact Precautions and Scope of Practice for Clostridioides difficile
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