Examkin

Question

Difficulty: HardBasic Care and Comfort

A practical nurse is providing basic care for an immobile client who is receiving continuous enteral tube feedings and requires frequent perineal care due to a *Clostridioides difficile* infection. Which of the following actions should the nurse take? (Select all that apply)

  1. Pause the enteral feeding infusion before lowering the head of the bed to turn the client.Answer
  2. Perform hand hygiene using soap and water rather than an alcohol-based hand rub after removing gloves.Answer
  3. Apply a moisture barrier ointment to the perineal skin after cleansing and patting the area dry.Answer
  4. D
    Remove personal protective equipment by taking off the mask first, followed by the gown and the soiled gloves.
  5. E
    Maintain the client in a flat, supine position after care is completed to evenly distribute body weight.
  6. F
    Prioritize finishing the soiled linen change over evaluating the client if sudden audible respiratory stridor occurs.

Answer

The correct actions are pausing the feeding pump before lowering the bed, performing hand hygiene with soap and water, and applying a moisture barrier ointment.
Safe basic care requires prioritizing airway protection, infection control, and skin integrity. Pausing the enteral feeding before lowering the head of the bed prevents regurgitation and fatal aspiration. Performing hand hygiene with soap and water is mandatory for *Clostridioides difficile*, as alcohol-based rubs cannot destroy the spores. Applying a moisture barrier ointment protects the vulnerable perineal skin from the corrosive effects of frequent diarrheal stools.

Step-by-Step Solution

1
Identify the client's risk factors related to continuous enteral feeding and immobility.
The client is at high risk for aspiration if the head is lowered while the feeding is running, and at risk for skin breakdown from frequent diarrhea.
Recognizing aspiration and skin breakdown risks determines the necessary safety and comfort interventions during basic care.
2
Determine the appropriate infection control measures for a client with C. diff.
C. diff spores are resistant to alcohol, so handwashing with soap and water is mandatory. PPE must be removed in the correct sequence (gloves first) to prevent self-contamination.
Adhering to standard and transmission-based precautions ensures safe care delivery and prevents pathogen spread during hygiene tasks.
3
Apply the ABC (Airway, Breathing, Circulation) framework to potential changes in condition.
Sudden stridor indicates a compromised airway, which is an immediate emergency.
The ABC framework mandates that airway issues must always take precedence over basic hygiene and comfort tasks.

Key Concept

Basic Care and Comfort integration with safety precautions
Rate this question

Topics

Basic Care and Comfort

More questions from this topic