A nurse is caring for a 9-year-old child at a clinic.

Vital Signs.

1000:. Temperature 36.8°C (98.2 °F). Heart rate 102/min.

Respiratory rate 22/min.

BP 100/60 mm Hg. Oxygen saturation is 98% on room air.

Nurses' Notes.

1000:.The child has been brought to the clinic by their parent due to a. report of right arm pain.

The parent states that several hours.

ago the child tripped and fell onto the sidewalk while playing.

outside.

The child states, "I was running when we were playing,and I tripped over a curb." The child is supporting their arm across.

their body.

Assessment.

1000:The child is alert and appears developmentally appropriate for their.

age and well nourished.

Respirations are easy and unlabored.

Abdomen nondistended.

The right forearm and fingers are edematous.

Ecchymotic area.

noted on the outer aspect of the forearm.

Radial pulse +2. Fingers.

slightly cool to the touch.

A child can move fingers and reports a mild.

"tingling" sensation.

The child verbalizes a pain level of 4 on a scale.

of 0 to 10. Abrasion noted on the right knee.

No active bleeding.

Multiple areas of bruising were noted on the lower extremities in various.

stages of healing.

The nurse should determine that the assessment findings are consistent with.

which of the following conditions? For each potential condition, click to specify if the assessment findings are.

consistent with a sprain, a fracture, or dislocation.

Each finding may support this.

more than 1 condition.

The correct answer isChoice D, remove the protective gown while in the client’s room.

Choice A rationale: Wearing a face shield is not specifically required for Clostridium difficile infection (CDI) precautions. CDI is primarily spread through the fecal-oral route, and while a face shield could provide protection against splashes during procedures that might generate them, it is not a standard precaution for entering the room of a patient with CDI.

Choice B rationale: Placing a mask on the client during transport is not a standard precaution for CDI. While it is important to prevent the spread of infection, CDI is not transmitted through the respiratory route, so a mask for the client would not be necessary in this context.

Choice C rationale: Using an alcohol-based hand rub is generally recommended for hand hygiene. However, for CDI, alcohol-based hand rubs are not effective against C. difficile spores. The Centers for Disease Control and Prevention (CDC) recommends washing hands with soap and water after caring for patients with CDI to physically remove the spores from the hands.

Choice D rationale: Removing the protective gown while still in the client’s room is the correct action to prevent the spread of contamination. Gowns should be removed before leaving the patient’s room to avoid dispersing contaminants to other areas of the healthcare facility.

Infection control for CDI involves several specific actions due to the resilience of C. difficile spores. These spores can survive on surfaces for a long time and are resistant to many common disinfectants, which is why environmental cleaning and disinfection with agents effective against C. difficile, such as bleach-based products, are crucial. Additionally, healthcare workers should use gloves and gowns when entering the rooms of patients with CDI and should ensure that these are disposed of correctly after use.

The correct answer is choice C: Initiate continuous cardiac monitoring.

Choice A rationale:

Implementing fluid restrictions is not recommended for a child with diabetic ketoacidosis (DKA). DKA is characterized by severe dehydration due to osmotic diuresis, and fluid replacement is a critical component of treatment to restore hydration and circulatory volume.

Choice B rationale:

Monitoring vital signs every 8 hours is not sufficient for a child with DKA. DKA is an acute, life-threatening condition that requires close monitoring of vital signs to detect changes in the patient’s condition promptly. Vital signs should be monitored more frequently, typically every 1 to 2 hours, depending on the severity of the DKA and institutional protocols.

Choice C rationale:

Continuous cardiac monitoring is recommended for a child with DKA. DKA can lead to serious electrolyte imbalances, such as hypokalemia, which can cause cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these potential complications.

Choice D rationale:

Administering subcutaneous insulin 30 minutes before meals is not appropriate for the acute management of DKA. In DKA, insulin is typically administered intravenously to rapidly decrease blood glucose levels and correct metabolic acidosis. Subcutaneous insulin is not used until the patient is stable and able to eat.