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 A

Explanation

Choice A: Potassium 2.5 mEq/L. This is the priority data collection finding that the nurse should identify according to the ABCDE principle, which prioritizes interventions based on airway, breathing, circulation, disability, and exposure. The nurse should identify potassium 2.5 mEq/L as the priority because it indicates hypokalemia, which is a low level of potassium in the blood. Potassium is an electrolyte that regulates the electrical activity of the heart and muscles. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and paralysis, which can be life-threatening.

Choice B: Blood glucose 150 mg/dL. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Blood glucose 150 mg/dL indicates hyperglycemia, which is a high level of glucose in the blood. Hyperglycemia can be caused by dehydration, stress, infection, or medication side eﬀects.

Hyperglycemia can cause symptoms such as polyuria, polydipsia, polyphagia, and fatigue. It can also lead to complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state, which are serious but not as urgent as hypokalemia.

Choice C: Urine specific gravity 1.035. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Urine specific gravity 1.035 indicates concentrated urine, which can be caused by dehydration or ﬂuid loss. Dehydration can result from vomiting and diarrhea, which are common symptoms of acute gastroenteritis. Dehydration can cause symptoms such as dry mucous membranes, tachycardia, hypotension, and oliguria. It can also lead to complications such as shock or kidney failure, which are serious but not as urgent as hypokalemia.

Choice D: Weight loss of 3% of total body weight. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Weight loss of 3% of total body weight indicates mild to moderate dehydration, which can be caused by ﬂuid loss from vomiting and diarrhea. Weight loss can also reﬂect loss of muscle mass or fat tissue due to malnutrition or inﬂammation. Weight loss can aﬀect the client’s nutritional status and immune function, but it is not as urgent as hypokalemia.

A. Faty stools B. Ecchymosis of the extremities C. Straw-colored urine D. Tenderness in the left upper abdomen

Correct Answer is A

Explanation

Choice A: Faty stools. This is a finding that is expected for a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis, which is the presence of gallstones in the gallbladder or bile ducts. The common bile duct carries bile from the liver and gallbladder to the duodenum, where it helps digest fats. If the common bile duct is obstructed by a gallstone, bile cannot reach the duodenum and fats cannot be properly absorbed. This results in fatty stools, which are also known as steatorrhea. Fatty stools are pale, bulky, greasy, and foul-smelling.

Choice B: Ecchymosis of the extremities. This is not a finding that is expected for a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis. Ecchymosis of the extremities is a sign of bleeding under the skin, which can be caused by trauma, coagulation disorders, or medications. It is not related to bile duct obstruction or gallstones.

Choice C: Straw-colored urine. This is not a finding that is expected for a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis. Straw-coloured urine is a normal colour of urine, which indicates adequate hydration and kidney function. It is not aﬀected by bile duct obstruction or gallstones.

Choice D: Tenderness in the left upper abdomen. This is not a finding that is expected for a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis. Tenderness in the left upper abdomen is a sign of splenomegaly, which is an enlargement of the spleen due to infection, inﬂammation, or cancer. It is not related to bile duct obstruction or gallstones.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has obstruction and inﬂammation of the common bile duct due to cholelithiasis. Which of the following findings is expected for this condition?

Correct Answer is A

Explanation

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