A nurse is assessing a client who is at 28 weeks of gestation and has a Clostridium difficile infection.
The nurse should initiate which of the following types of isolation precautions for the client?
Droplet.
Airborne.
Protective environment.
Contact.
The Correct Answer is D
Choice A rationale:
Droplet precautions are used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples: pneumonia, influenza, whooping cough, bacterial meningitis). This is not the case with Clostridium difficile.
Choice B rationale:
Airborne precautions are used for diseases or germs that are spread through the air (examples: tuberculosis, measles, chickenpox). This is not the case with Clostridium difficile.
Choice C rationale:
A protective environment is a room designed to reduce the risk of infections from airborne, droplet, and contact transmissions. It’s typically for patients who have undergone stem cell transplants. This is not necessary for Clostridium difficile.
Choice D rationale:
Contact precautions are used for diseases or germs that are spread by touching the patient or items in the room (examples: MRSA, VRE, diarrheal illnesses, open wounds). Clostridium difficile is spread via contact, hence contact precautions are appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Placing the client in a semi-Fowler’s position for 1 hr after administration is not necessary.
Choice B rationale:
Allowing the medication to reach room temperature prior to administration is not necessary.
Choice C rationale:
Instructing the client to avoid urinary elimination until after administration is not necessary.
Choice D rationale:
Verifying that informed consent is obtained prior to administration is crucial as it ensures the client is aware of the procedure and its potential risks.
Correct Answer is D
Explanation
Choice A rationale:
A 21-gauge needle is too large for a heel stick on a newborn.
Choice B rationale:
Alcohol can cause skin irritation and should not be used after the procedure.
Choice C rationale:
A warm cloth, not a cool one, should be applied to the site before the procedure to enhance circulation.
Choice D rationale:
The lateral side of the heel is the correct site for a heel stick to avoid injury to the bone.
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