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 B
Explanation
A. Contacting the provider within 48 hr is incorrect. A prescription for restraints must be obtained within 1 hour of applying restraints, not within 48 hours. The nurse should ensure that this prescription is obtained promptly.
B. Removing the restraints every 2 hr is correct. The nurse should remove the restraints every 2 hours to assess the skin, provide range-of-motion exercises, and offer comfort. This ensures that the client is not harmed from prolonged restraint use.
C. Checking that one finger fits between the client's wrists and the restraints is incorrect. The nurse should ensure that the restraints are snug but not too tight to cause injury, typically allowing for two fingers of space, not just one.
D. Fastening the restraints' ties to the bed's side rails is incorrect. Restraints should be fastened to a movable part of the bed frame (not side rails) to prevent injury or accidental strangulation. The side rails can move and cause undue tension on the restraints.
Correct Answer is C
Explanation
A. Tachypnea: Tachypnea (rapid breathing) is not a typical effect of magnesium sulfate. Magnesium sulfate is more likely to cause respiratory depression, especially at higher doses, rather than increasing the rate of breathing.
B. Tachycardia: Tachycardia (rapid heart rate). is not a common finding with magnesium sulfate administration. Magnesium sulfate typically causes a decrease in heart rate (bradycardia. and may also contribute to hypotension.
C. Hypotension: Hypotension is the correct finding. Magnesium sulfate has a vasodilatory effect, which can lead to a drop in blood pressure. This is a well-known side effect of magnesium sulfate, particularly when administered intravenously.
D. Hyperthermia: Hyperthermia (elevated body temperature). is not a typical finding associated with magnesium sulfate. Instead, magnesium sulfate can sometimes cause mild flushing, but it does not generally lead to an increase in body temperature.
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