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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A: Purple striations. These are also known as striae, and they are caused by the thinning and weakening of the skin and underlying connective tissue due to cortisol. They appear as purple or red lines on the abdomen, thighs, breasts, or arms.
Choice C: Buffalo hump. This is a term used to describe the accumulation of fat on the upper back and neck due to cortisol. It gives the appearance of a hump or a rounded shape.
Choice E: Moon face. This is a term used to describe the rounding and fullness of the face due to cortisol. It gives the
appearance of a moon-like shape.
Choice B: Tremors. These are not a clinical manifestation of Cushing’s syndrome, but rather a sign of hyperthyroidism, which is a condition caused by excess thyroid hormone production or exposure. Thyroid hormone affects the nervous system and causes increased muscle activity and tremors.
Choice D: Obese extremities. These are not a clinical manifestation of Cushing’s syndrome, but rather a sign of hypothyroidism, which is a condition caused by low thyroid hormone production or exposure. Thyroid hormone affects the metabolism of carbohydrates, proteins, and fats, and causes decreased energy expenditure and weight gain.
Correct Answer is B
Explanation
Choice A: Upper left quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The upper left quadrant of the abdomen contains organs such as the stomach, spleen, pancreas, and part of the colon. Abdominal pain in this area can indicate conditions such as gastritis, peptic ulcer, pancreatitis, splenomegaly, or colon cancer.
Choice B: Lower left quadrant. This is the location where the nurse should expect the client to report abdominal pain who has diverticular disease, which is a condition that involves the formation of pouches or sacs in the wall of the colon. These pouches or sacs are called diverticula, and they can become inflamed or infected, causing diverticulitis. Diverticulitis can cause abdominal pain, fever, nausea, vomiting, and changes in bowel habits. The most common site of diverticula formation and diverticulitis is the sigmoid colon, which is located in the lower left quadrant of the abdomen.
Choice C: Upper right quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The upper right quadrant of the abdomen contains organs such as the liver, gallbladder, duodenum, and part of the colon. Abdominal pain in this area can indicate conditions such as hepatitis, cholecystitis, duodenal ulcer, or colon cancer.
Choice D: Lower right quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The lower right quadrant of the abdomen contains organs such as the appendix, cecum, and part of the colon. Abdominal pain in this area can indicate conditions such as appendicitis, Crohn’s disease, or colon cancer.
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