A nurse is caring for a client who has developed a Clostridium difficile infection following antibiotic therapy. Which of the following actions should the nurse take?

Implement neutropenia isolation.

Use alcohol hand sanitizer following client care.

Monitor the client for manifestations of ﬂuid overload.

Disinfect equipment with bleach solution

Answer and Explanation

The Correct Answer is D

Choice A: Implement neutropenia isolation. This is not an action that the nurse should take for a client who has developed a Clostridium difficile infection. Neutropenia isolation is a type of protective isolation that is used for

clients who have low white blood cell counts and are at risk of infection from others. It is not indicated for clients who have Clostridium difficile infection, which is not transmited through the air.

Choice B: Use alcohol hand sanitizer following client care. This is not an action that the nurse should take for a client who has developed a Clostridium difficile infection. Alcohol hand sanitizer is ineﬀective against Clostridium difficile spores and can increase the risk of transmission. The nurse should wash their hands with soap and water, which can remove the spores from the skin.

Choice C: Monitor the client for manifestations of ﬂuid overload. This is not an action that the nurse should take for a client who has developed a Clostridium difficile infection. Fluid overload is a condition that occurs when the body retains excess ﬂuid and causes symptoms such as edema, dyspnea, and hypertension. It is not related to Clostridium difficile infection, which can cause ﬂuid loss due to diarrhea and dehydration. The nurse should monitor the client for manifestations of ﬂuid deficit, such as dry mucous membranes, tachycardia, and hypotension.

Choice D: Disinfect equipment with bleach solution. This is an action that the nurse should take for a client who has developed a Clostridium difficile infection, which is a bacterial infection that causes severe diarrhea and inﬂammation of the colon. Clostridium difficile spores are resistant to most disinfectants and can survive on surfaces for a long time. The nurse should disinfect equipment with bleach solution, which can kill the spores and prevent transmission.

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Correct Answer is D

Explanation

Choice A: Notify the nurse manager. This is an important action that the nurse should take, but not a priority. The nurse should notify the nurse manager to report the error and seek guidance on how to proceed. The nurse manager can also provide support and feedback to the nurse and help prevent similar errors in the future.

Choice B: Give the client 15 to 20 g of carbohydrate. This is a necessary action that the nurse should take, but not the priority. The nurse should give the client 15 to 20 g of carbohydrates to raise their blood glucose level and prevent or treat hypoglycemia. The nurse should choose a fast-acting carbohydrate source, such as juice, glucose tablets, or candy.

Choice C: Complete an incident report. This is a required action that the nurse should take, but not the priority. The nurse should complete an incident report to document the error and its consequences. The incident report can help identify the root cause of the error and improve patient safety and quality of care.

Choice D: Check the client’s blood glucose level. This is the priority action that the nurse should identify according to the ABCDE principle, which prioritizes interventions based on airway, breathing, circulation, disability, and exposure. The nurse should check the client’s blood glucose level to confirm the error and assess the risk of hypoglycemia, which is a low level of glucose in the blood. Hypoglycemia can cause symptoms such as sweating, trembling, confusion, and loss of consciousness. It can be life-threatening if not treated promptly.

A. Drinking orange juice regularly B. Eating dinner early in the evening C. Consuming low-fat meats D. Sleeping on a large wedge-style pillow

Correct Answer is A

Explanation

Choice A: Drinking orange juice regularly. This is a contributing factor to the client’s heartburn because orange juice is acidic and can irritate the esophageal mucosa and lower esophageal sphincter, causing reﬂux of gastric contents into the esophagus.

Choice B: Eating dinner early in the evening. This is not a contributing factor to the client’s heartburn, but rather a recommended action for the client to prevent heartburn. The client should avoid eating within 3 hours of bedtime to allow for gastric emptying and reduce the risk of reﬂux.

Choice C: Consuming low-fat meats. This is not a contributing factor to the client’s heartburn, but rather a recommended action for the client to prevent heartburn. The client should avoid high-fat foods, which can delay gastric emptying and increase intra-abdominal pressure, leading to reﬂux.

Choice D: Sleeping on a large wedge-style pillow. This is not a contributing factor to the client’s heartburn, but rather a recommended action for the client to prevent heartburn. The client should elevate the head of their bed or use a wedge pillow to create an incline that prevents gastric contents from ﬂowing back into the esophagus.

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A nurse is caring for a client who has developed a Clostridium difficile infection following antibiotic therapy. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

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