A nurse is caring for a client.

Exhibits

Which of the following actions should the nurse take? Select all that apply.

Wear a protective gown while caring for the client.

Place the client in a private room.

Wear an N-95 respirator while caring for the client.

Place the client in a negative pressure room.

Place a mask on the client when they leave their room.

Answer and Explanation

Correct Answer : A,B

The correct answer is Choice A, Choice B

Choice A rationale: Clostridium difficile is a spore-forming, gram-positive anaerobic bacillus that causes antibiotic-associated colitis. Transmission occurs via the fecal-oral route, primarily through contact with contaminated surfaces or hands. Protective gowns are essential during care to prevent spore transfer to clothing and subsequent environmental contamination. Spores resist alcohol-based sanitizers and persist on surfaces for months. Contact precautions, including gown use, reduce nosocomial spread. Normal white blood cell count is 4,000–11,000/mm³; elevated levels may indicate infection severity.

Choice B rationale: Isolation in a private room is critical for clients with confirmed Clostridium difficile infection due to the organism’s ability to form resilient spores that contaminate surfaces and equipment. Private rooms limit environmental exposure and reduce cross-contamination risk. C. difficile spores are resistant to routine cleaning agents and require bleach-based disinfectants. Diarrheal stool volume increases transmission risk. Normal stool frequency is 1–3 formed stools/day; 4–5 liquid stools/day indicates active infectious diarrhea requiring isolation.

Choice C rationale: N-95 respirators are designed for airborne pathogens such as Mycobacterium tuberculosis, measles virus, or varicella-zoster virus. Clostridium difficile is not airborne; it transmits via contact with contaminated surfaces or hands. Spores are shed in feces and do not aerosolize under normal conditions. Therefore, N-95 respirators offer no added protection against CDI. Airborne precautions are unnecessary unless aerosol-generating procedures are performed on patients with concurrent airborne infections. Respiratory rate normal range is 12–20 breaths/min.

Choice D rationale: Negative pressure rooms are used to contain airborne pathogens by maintaining lower air pressure inside the room, preventing contaminated air from escaping. Clostridium difficile does not spread via airborne particles but through contact with contaminated surfaces and feces. Thus, negative pressure rooms are not scientifically justified for CDI. Instead, contact isolation and environmental decontamination are prioritized. Room air exchanges are irrelevant to CDI control. Normal room air pressure is neutral unless airborne precautions are indicated.

Choice E rationale: Masking the client is a droplet precaution used for pathogens like influenza virus, Neisseria meningitidis, or SARS-CoV-2. Clostridium difficile does not transmit via respiratory droplets, so placing a mask on the client during transport does not reduce transmission risk. Instead, hand hygiene and contact precautions are essential. CDI spores are not expelled via coughing or sneezing. Droplet precautions are reserved for pathogens with particle size >5 µm. Normal oxygen saturation is ≥95% on room air.

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Correct Answer is C

Explanation

Choice A rationale:

A heart rate of 56 beats per minute is within the normal range for an adult, so a high temperature of 39°C (102.2°F) is not directly related to the heart rate. While elevated body temperature can increase heart rate, the given temperature does not indicate a significant fever.

Choice B rationale:

History of cigarette smoking may be a risk factor for cardiovascular issues, but it does not directly correlate with the current heart rate of 56 beats per minute. The low heart rate is more likely related to other factors.

Choice C rationale:

A heart rate of 56 beats per minute is considered bradycardia, which can lead to dizziness, fatigue, and other symptoms. Dizziness is a common finding in individuals with a slow heart rate, and addressing this symptom is essential for patient safety.

Choice D rationale:

Hypoglycemia (low blood sugar) can cause symptoms like dizziness, but the heart rate is not typically affected directly by hypoglycemia. It is important to address both the bradycardia and the reported dizziness to determine the underlying cause and provide appropriate care.

A. A client is scheduled to receive an influenza vaccination. B. A client who has a family history of breast cancer is scheduled for a mammogram. C. A client who is asymptomatic is not scheduled for a series of tests. D. A client who has heart failure is scheduled for an echocardiogram.

Correct Answer is B

Explanation

The correct answer is Choice B: A client who has a family history of breast cancer is scheduled for a mammogram.

Choice A rationale:

Receiving an influenza vaccination is an example of primary prevention, which aims to prevent the onset of disease.

Choice B rationale:

Scheduling a mammogram for a client with a family history of breast cancer is an example of secondary prevention. Secondary prevention involves the early detection and treatment of disease to reduce the impact of the disease. Mammograms help in the early detection of breast cancer, which can significantly improve treatment outcomes.

Choice C rationale:

Not scheduling tests for an asymptomatic client does not relate to secondary prevention. Secondary prevention involves screening and early detection of diseases in at-risk populations.

Choice D rationale:

Scheduling an echocardiogram for a client with heart failure is an example of tertiary prevention. Tertiary prevention aims to reduce the impact of an ongoing illness or injury that has lasting effects by helping patients manage long-term, complex health problems.

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A nurse is caring for a client. Exhibits Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

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A nurse is caring for a client.

Exhibits

Which of the following actions should the nurse take? Select all that apply.