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. Denial is incorrect. Denial involves refusing to acknowledge reality or a distressing situation, which is not evident in this scenario. The adolescent is aware of the conflict and has chosen a constructive way to address it.
B. Sublimation is correct. Sublimation is the process of channeling unacceptable impulses (such as frustration or aggression) into socially acceptable activities (such as sports or creative pursuits). By joining the track and field team instead of arguing with his brothers, the adolescent is redirecting energy into a positive outlet.
C. Regression is incorrect. Regression occurs when an individual reverts to an earlier stage of development in response to stress. Examples include an older child suddenly sucking their thumb or having temper tantrums. The adolescent in this scenario is demonstrating maturity, not regression.
D. Repression is incorrect. Repression involves unconsciously blocking distressing thoughts or emotions from awareness. The adolescent is not avoiding or forgetting about the conflict but is instead managing it through physical activity.
Correct Answer is C
Explanation
A. Having the client point his toes before inserting his foot into the stocking is incorrect. The nurse should instruct the client to keep the foot in a neutral position to avoid unnecessary pressure on the toes or veins.
B. Removing the stockings once every 24 hr is incorrect. Antiembolic stockings should typically be removed and reapplied at least once per shift to allow for skin assessment and hygiene. They should not remain on for 24 hours continuously.
C. Elevating the client's legs for 5 min prior to applying the stockings is correct. Elevating the legs helps promote venous return by reducing swelling in the lower extremities. This makes the application of antiembolic stockings more effective and more comfortable for the client.
D. Rolling the top of the stocking down so it fits snugly above the client's calf is incorrect. The stockings should be applied smoothly and without folds to avoid restricting circulation. The top should not be rolled down as it can create pressure points
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