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 D

Explanation

Rationale:

A. "Playing music will increase my husband's alertness.": Music therapy is not primarily used to increase alertness in hospice clients. Soothing music may promote relaxation and even drowsiness, especially in clients receiving sedating medications for or end-of-life comfort.

B. "I will discontinue music therapy when my husband is no longer responsive": Music therapy can still provide comfort even when a client is unresponsive. Familiar or calming music may have soothing effects and contribute to emotional peace, making it appropriate throughout all stages of hospice care.

C. "My husband won't need medication for breakthrough pain while using music therapy.": Music therapy is a complementary technique, not a replacement for pharmacologic pain management. Clients may still require medications for breakthrough pain.

D. "Music will distract my husband's awareness of the pain.": Music therapy helps reduce the perception of pain by providing sensory distraction and promoting relaxation. This cognitive diversion is one of the key benefits of using music as part of holistic pain management in hospice care.

A. The client's next dressing change is scheduled in 4 hr. B. The client has developed difficulty ambulating C. The client's vital signs are checked every 8 hr. D. The client has state-sponsored health insurance.

Correct Answer is B

Explanation

Rationale:

A. The client's next dressing change is scheduled in 4 hr.: This is routine scheduling information that does not require input from the entire interprofessional team. It is more relevant for shift handoff or task tracking than for collaborative care planning.

B. The client has developed difficulty ambulating: New or worsening mobility issues can impact the client’s safety, rehabilitation needs, discharge planning, and therapy referrals. This information is essential for all members of the interprofessional team, including physical therapists and case managers.

C. The client's vital signs are checked every 8 hr.: This detail reflects standard monitoring protocol and does not provide meaningful insight into the client’s current health status or changes that would impact team planning or intervention.

D. The client has state-sponsored health insurance: While insurance type may influence discharge or equipment planning, it is handled by social services or case management. It is not the most relevant information to bring forward in a clinical team meeting.

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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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Explanation

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