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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. WBC 13,000/mm3 is slightly elevated and might indicate an infection, but it is not critically high in the context of COPD. The nurse should still monitor the client for signs of infection but is unlikely to require immediate intervention.
B. Potassium 3.7 mEq/L is within the normal range (3.5–5.0 mEq/L) and does not require reporting.
C. Hgb 20 g/dL is elevated and should be reported. High hemoglobin levels can indicate dehydration, polycythemia, or other conditions related to chronic hypoxia, which is common in COPD. This value is above the normal range (12–18 g/dL for adults) and requires further evaluation.
D. Iron 150 mcg/dL is within the normal range (50–170 mcg/dL for adults) and does not require reporting.
Correct Answer is C
Explanation
A. Turning on overhead lights briefly when checking IV lines is incorrect. Bright lights can disrupt sleep cycles, especially for clients who are light-sensitive or have fragmented sleep patterns. Instead, using a flashlight or bedside lamp is recommended to minimize disturbances.
B. Opening curtains between clients in semiprivate rooms is incorrect. Keeping curtains closed provides privacy and helps block light and noise, both of which can interfere with restful sleep.
C. Wearing shoes with rubber soles is correct. Rubber-soled shoes reduce noise from footsteps, minimizing disturbances in client rooms and creating a quieter environment that promotes sleep.
D. Conducting change-of-shift report near the clients' rooms is incorrect. Shift reports should be conducted away from patient areas to prevent unnecessary noise and disruption during sleep hours.
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