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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:

A. Tilt the client's head forward during meals: Tilting the head forward, also known as the chin-tuck technique, helps close the airway and reduce the risk of aspiration in clients with dysphagia. This position facilitates safer swallowing by improving bolus control and airway protection.

B. Encourage socialization during meal times: While social interaction is generally beneficial, clients with dysphagia require focused attention during meals to prevent choking or aspiration. Distractions can compromise concentration on swallowing techniques and safety precautions.

C. Elevate the head of the client's bed to 30": Although elevating the head of the bed helps reduce aspiration risk, a 30" elevation is not optimal for swallowing. A 45–90 degree upright position is typically recommended during meals to support safer swallowing mechanics.

D. Provide three large meals per day: Clients with dysphagia benefit more from small, frequent meals to reduce fatigue and lower the risk of aspiration. Large meals can overwhelm their ability to chew and swallow safely, increasing the risk of complications.

A. Occupational therapist B. Social worker C. Primary care provider D. Physical therapist

Correct Answer is B

Explanation

Rationale:

A. Occupational therapist: An occupational therapist helps clients regain skills for daily living and can assess driving ability, but they are not typically responsible for arranging transportation or addressing confidence-related psychosocial issues. A referral may follow but is not the first step here.

B. Social worker: A social worker assists clients with coping and resource coordination, including transportation services, community support, and addressing emotional or confidence barriers. This makes them the most appropriate referral when a client is unsure about attending follow-up care.

C. Primary care provider: While the PCP oversees general medical care and referrals, they are not responsible for coordinating transportation. The nurse can directly initiate a more appropriate referral rather than relying on the PCP for this non-medical concern.

D. Physical therapist: A physical therapist focuses on improving physical function, mobility, and strength. They do not handle transportation issues or confidence concerns related to attending appointments, making them less relevant in this context.

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A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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