A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxyphenol-methamphetamine. Which of the following findings should the nurse expect?

Explanation

C. Initiate contact precautions

Clostridium difficile is a bacterium that causes diarrhea and can be easily transmitted from person to person. Contact precautions are necessary to prevent the spread of the infection. This includes wearing gloves and a gown when providing direct care to the child, ensuring proper hand hygiene, and implementing proper disinfection protocols for the environment.

The other options are not necessary or specific to the care of a child with Clostridium difficile:

Using an N95 respirator in (option A) is not necessary for the care of a child with Clostridium difficile. Respirators are typically used for airborne precautions, which are not indicated for this specific infection.

Instructing the parents to avoid bringing fresh flowers into the room in (option)is not specific to the care of a child with Clostridium difficile. While it is generally recommended to minimize potential sources of contamination in healthcare settings, this particular instruction is not specific to this infection.

Placing the child in a room with a HEPA filtration system in (option D) is not necessary for the care of a child with Clostridium difficile. HEPA filtration systems are typically used for airborne precautions, which are not indicated for this specific infection.

The presence of edema and coolness around the catheter's insertion site suggests that infiltration may have occurred. Infiltration refers to the unintended leakage of fluid into the surrounding tissues instead of flowing into the vein. It can lead to tissue damage and compromised circulation. Stopping the infusion is the initial priority to prevent further infiltration and minimize potential harm to the client.

Applying a warm compress may be appropriate to promote comfort and circulation in some cases, but it should be done after stopping the infusion and assessing the severity of the infiltration.

Documenting the infiltration is necessary for accurate record-keeping and to communicate the occurrence to the healthcare team. However, it is not the first immediate action required in this situation.

Elevating the arm can help reduce swelling and promote venous return. It can be done after stopping the infusion, but it is not the first action to address the potential infiltration.