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

Instruct the parents to avoid bringing fresh flowers into the room.

Use an N95 respirator.

Initiate contact precautions.

Place the child in a room that has a HEPA filtration system.

Answer and Explanation

The Correct Answer is C

A. Avoiding fresh flowers in the room is unnecessary for a child with Clostridium difficile. Fresh flowers are typically restricted for clients who are immunocompromised, such as those undergoing chemotherapy or organ transplants, rather than those with infectious diarrhea.

B. Using an N95 respirator is incorrect. Clostridium difficile is transmitted via the fecal-oral route and requires contact precautions, not airborne precautions. An N95 mask is only required for airborne pathogens like tuberculosis or measles.

C. Initiating contact precautions is correct. Clostridium difficile is highly contagious and spreads through spores that can survive on surfaces. Contact precautions, including the use of gloves and gowns and proper hand hygiene with soap and water, help prevent transmission.

D. Placing the child in a room with a HEPA filtration system is unnecessary. HEPA filtration is used for airborne pathogens, whereas Clostridium difficile is spread via direct and indirect contact rather than through the air.

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Correct Answer is A

Explanation

A. Heart rhythm: This is correct. Hypothermia, indicated by a body temperature of 32.5°C (90.5°F), can affect the cardiovascular system, potentially causing arrhythmias or even cardiac arrest. Monitoring heart rhythm is critical because of the risk of life-threatening cardiac complications associated with severe hypothermia.

B. Urinary output: While urinary output may decrease in hypothermic conditions due to vasoconstriction, it is not the priority. Cardiac function takes precedence, as severe hypothermia can lead to fatal arrhythmias.

C. Pain sensation: Although decreased pain sensation can occur in hypothermia, it is less urgent to monitor compared to the potential for life-threatening arrhythmias or cardiac arrest.

D. Muscle strength: While hypothermia can impair muscle strength, it is not the priority compared to monitoring for cardiac irregularities, which can be fatal if left unchecked.

A. “Discontinue the medication. I will ask your provider for another antibiotic.” B. “That reaction means your dose is too high. Cut the pill in half.” C. “Continue to take the medication. Calf pain is a minor reaction that will resolve itself.” D. “This is an allergic reaction. Take the medication with an antihistamine.”

Correct Answer is A

Explanation

A. “Discontinue the medication. I will ask your provider for another antibiotic.”: This is correct. Ciprofloxacin and other fluoroquinolones are associated with a risk of tendonitis and tendon rupture, particularly in the Achilles tendon. The pain in the calf muscle could indicate this side effect. The nurse should recommend discontinuing the medication and notifying the provider for further evaluation.

B. “That reaction means your dose is too high. Cut the pill in half.”: This is incorrect. The pain in the calf muscle is likely related to a known side effect of ciprofloxacin, rather than the dose being too high. Adjusting the dose is not the appropriate solution.

C. “Continue to take the medication. Calf pain is a minor reaction that will resolve itself.”: This is incorrect. Calf pain may be indicative of a serious side effect, such as tendonitis or tendon rupture, and the medication should be discontinued until the provider evaluates the client.

D. “This is an allergic reaction. Take the medication with an antihistamine.”: This is incorrect. The pain in the calf muscle is more likely due to tendon-related side effects, not an allergic reaction. Ciprofloxacin-related tendon pain requires immediate attention, and antihistamines would not address the underlying issue.

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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

A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5°C (90.5°F). Which of the following data is the priority for the nurse to monitor?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has a urinary tract infection and is taking ciprofloxacin. The client reports pain in her calf muscle. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

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