A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?
Use an N95 respirator.
Initiate contact precautions
Place the child in a room that has a HEPA filtration system.
Instruct the parents to avoid bringing fresh flowers into the room.
The Correct Answer is B
Rationale:
A. Use an N95 respirator: N95 respirators are necessary for airborne precautions, such as with tuberculosis or measles. C. difficile is transmitted via contact with contaminated surfaces or stool, not airborne particles, so an N95 is not indicated.
B. Initiate contact precautions: Contact precautions are required for C. difficile because it spreads through direct and indirect contact with contaminated surfaces or stool. Gloves and gowns should be worn, and hand hygiene with soap and water is essential to prevent spore transmission.
C. Place the child in a room that has a HEPA filtration system: HEPA filters are used for airborne pathogens or immunocompromised clients, not for enteric infections like C. difficile. This intervention would not reduce transmission risk in this case.
D. Instruct the parents to avoid bringing fresh flowers into the room: This precaution is typically for neutropenic or immunocompromised clients to reduce exposure to potential fungal spores. C. difficile precautions focus on containment of fecal-oral transmission routes, not environmental fungal sources.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Alternative care provider: An alternative care provider may offer complementary therapies such as acupuncture or herbal treatments, but they are not specifically trained to assist with functional difficulties related to ADLs.
B. Nutritionist: A nutritionist can help manage diet and nutritional concerns, however, they do not specialize in helping clients adapt to challenges with cooking and eating caused by joint stiffness or pain.
C. Occupational therapist: An occupational therapist specializes in helping individuals adapt to physical limitations that interfere with daily living tasks. They can assess the client's needs and provide strategies, tools, and exercises to enhance independence with activities such as cooking and eating.
D. Dentist: A dentist focuses on oral health and is not involved in helping clients manage limitations in performing ADLs. This referral would be unrelated to the client's current difficulty managing tasks due to rheumatoid arthritis.
Correct Answer is A
Explanation
Rationale:
A. "Discontinue the medication. I will ask your provider for another antibiotic.": Calf pain in a client taking ciprofloxacin may indicate tendinitis or even tendon rupture, a serious adverse effect associated with fluoroquinolones. The nurse should advise discontinuation of the drug and alert the provider immediately to prevent permanent damage.
B. "That reaction means your dose is too high. Cut the pill in half.": Reducing the dose without provider approval is unsafe and does not address the underlying risk of tendon injury. Ciprofloxacin-related tendinopathy is not dose-dependent and requires immediate discontinuation.
C. "Continue to take the medication. Calf pain is a minor reaction that will resolve itself.": Calf pain during ciprofloxacin therapy should never be dismissed as minor, since it may signal tendon inflammation or rupture.
D. “This is an allergic reaction. Take the medication with an antihistamine.": Tendon-related adverse effects are not allergic reactions and will not respond to antihistamines. Misclassifying the symptom as an allergy delays the proper intervention and increases the risk of irreversible tendon damage.
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