A nurse is caring for a client.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E","F"]
Explanation
Choice A rationale:
Givingtheclientprintedinformationisaneducationalmethodthatinvolvesreadingandcomprehension,whicharekeycomponentsofthecognitivedomain.
Choice B rationale:
Teaching about expected reference ranges and target blood glucose levels is based on the cognitive domain of learning. This involves understanding and comprehending information, which is a key aspect of cognitive learning. It's important for a client with diabetes to know what their blood glucose levels should be and what values to aim for to manage their condition effectively.
Choice C rationale:
Asking the client how they feel about checking their blood glucose levels is related to the affective domain of learning. It focuses on the client's emotions and attitudes rather than cognitive understanding, which is not directly mentioned in the question.
Choice D rationale:
Asking the client to demonstrate checking their blood glucose level is based on the psychomotor domain of learning. This involves physical skills and actions, which are not explicitly mentioned in the question.
Choice E rationale:
Giving the client a fill-in-the-blank quiz is also based on the cognitive domain of learning. Quizzes and assessments are tools that help assess a client's understanding and retention of information, which aligns with cognitive learning.
Choice F rationale:
Asking the client to describe the manifestations of hypoglycemia and hyperglycemia is also based on the cognitive domain of learning. It requires the client to recall and explain information, which is a cognitive process.
Correct Answer is B
Explanation
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