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 ["B","D","E"]

Explanation

A. Hypoglycemic: Hypoglycemia is not typically considered a sign or symptom of sepsis. In sepsis, blood glucose levels may fluctuate, but hypoglycemia is less common.
B. Elevated White Blood Count: An elevated white blood count (leukocytosis) is a common sign of sepsis, indicating the body's immune response to infection.
C. Pruritus: Pruritus, or itching, is not typically associated with sepsis. Itching may occur in certain skin conditions or allergic reactions but is not a hallmark sign of sepsis.
D. Hypotension: Hypotension, or low blood pressure, is a serious sign of sepsis and can indicate septic shock, a life-threatening complication.
E. Altered Mental Status: Altered mental status, such as confusion, disorientation, or decreased level of consciousness, can occur in sepsis due to systemic inflammation and impaired perfusion to the brain.

A. Avoiding use of a urinary catheter B. Applying absorbent briefs C. Restricting Fluids D. Toileting patient every 4 hours

Correct Answer is B

Explanation

A. Avoiding use of a urinary catheter: While avoiding unnecessary urinary catheterization is important to prevent healthcare-associated urinary tract infections, this action may not be directly applicable to an incontinent patient who requires interventions to manage incontinence.
B. Applying absorbent briefs: Using absorbent briefs helps contain urine and feces, reducing the risk of skin breakdown and contamination of the environment.
C. Restricting Fluids: Restricting fluids may lead to dehydration and is not a recommended approach for preventing healthcare-associated infections in incontinent patients.
D. Toileting patient every 4 hours: Toileting frequency should be individualized based on the patient's needs and not restricted to a specific time interval. Additionally, simply toileting the patient may not be sufficient to prevent healthcare-associated infections if proper hygiene practices are not followed.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has an infection. Which of the following findings are signs and symptoms of sepsis? (Select All that Apply.)

Correct Answer is ["B","D","E"]

Explanation

Which of the following actions can the nurse take to help prevent a health care-associated infection in an incontinent patient?

Correct Answer is B

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.