A nurse is assisting with the care of a client with the history below:

Exhibits

A nurse is caring for the client. Which of the following actions should the nurse take? Select (2) answers that apply.

Wear a protective gown while caring for the client.

Place the client in a private room.

Wear an N-95 respirator while caring for the client.

Place the client in a negative pressure room.

Place a mask on the client when they leave their room.

Answer and Explanation

Correct Answer : A,B

A. Wearing a protective gown is necessary when caring for a client with C. difficile to prevent the spread of spores and protect the nurse from contact with contaminated surfaces.
B. Placing the client in a private room helps to isolate the infection and prevent transmission to other patients, which is essential in managing C. difficile infections.
C. An N-95 respirator is not required for C. difficile as the primary mode of transmission is via the fecal-oral route, not through airborne particles.
D. A negative pressure room is used for airborne infections like tuberculosis, not for C. difficile. C. difficile requires contact precautions rather than airborne precautions.
E. A mask is not necessary for the client with C. difficile when leaving the room; instead, hand hygiene and proper gowning are essential for preventing the spread of the infection.

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Correct Answer is A

Explanation

A. Place all clients who have manifestations on contact precautions: Given the suspicion of Clostridium difficile infection due to the development of watery diarrhea in multiple clients, it is appropriate to place these clients on contact precautions until the diagnosis is confirmed or ruled out. Contact precautions help prevent the spread of the infection by requiring healthcare workers to wear gloves and gowns when entering the room.
B. Obtain stool cultures from all clients on the nursing unit: While obtaining stool cultures may be necessary to confirm the diagnosis of C. difficile infection, implementing contact precautions is more immediate and necessary to prevent transmission.
C. Request the providers to initiate antibiotic therapy for every client on the unit: Initiating antibiotic therapy for every client on the unit without confirmation of C. difficile infection is not appropriate and may contribute to antibiotic resistance.

D. Perform hand hygiene with an alcohol-based agent: Hand hygiene is essential in preventing the spread of infection, but in the case of C. difficile, handwashing with soap and water is recommended over alcohol-based hand sanitizers due to the spore-forming nature of the bacteria.

A. A client who has swelling, tenderness, and purulent drainage around the wound B. A client who has urticaria and itching around the wound C. A client who has serosanguineous drainage from the wound D. A client who has brown crusting over the wound

Correct Answer is A

Explanation

A. Swelling, tenderness, and purulent drainage around the wound are classic signs of a wound infection. Swelling and tenderness indicate inflammation, while purulent drainage (pus) suggests the presence of infection.
B. Urticaria and itching around the wound are more indicative of an allergic reaction or hypersensitivity rather than a wound infection.
C. Serosanguineous drainage (clear to blood-tinged fluid) is a normal finding in the early stages of wound healing and does not necessarily indicate infection.
D. Brown crusting over the wound may indicate the formation of an eschar, which can occur in wounds undergoing healing, particularly in wounds with necrotic tissue. It is not necessarily indicative of infection unless accompanied by other signs such as erythema, warmth, or purulent drainage.

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A nurse is assisting with the care of a client with the history below: Exhibits A nurse is caring for the client. Which of the following actions should the nurse take? Select (2) answers that apply.

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Naxlex Comprehensive Predictor Exams

A nurse working on a medical-surgical unit suspects that several clients have Clostridium Difficile (C-Diff) when they all develop watery diarrhea. Which of the following actions should the nurse plan to take while waiting for the client's lab results?

Correct Answer is A

Explanation

A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?

Correct Answer is A

Explanation

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A nurse is assisting with the care of a client with the history below:

Exhibits

A nurse is caring for the client. Which of the following actions should the nurse take? Select (2) answers that apply.