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
Explanation
Choice A: Check for bleeding on the dressing at the back of the client’s neck. This is an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy, which is a surgical removal of part of the thyroid gland. The nurse should check for bleeding on the dressing at the back of the client’s neck because this is where blood can pool and go unnoticed. Bleeding can cause hematoma, compression of the airway, and respiratory distress.
Choice B: Ensure that acetylcysteine IV is readily available. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. Acetylcysteine IV is an antidote for acetaminophen overdose, which can cause liver damage, but it is not related to thyroid surgery.
Choice C: Place the client in a side-lying position. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. The nurse should place the client in a semi-Fowler’s position, which is a position with the head of the bed elevated to 30 to 45 degrees. This position can facilitate breathing, reduce edema, and prevent aspiration.
Choice D: Check the client for asterixis. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. Asterixis is a sign of hepatic encephalopathy, which is a condition caused by liver failure, but it is not related to thyroid surgery.
Correct Answer is C
Explanation
Choice A: Hypernatremia. This is not a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease. Hypernatremia is a high level of sodium in the blood, which can be caused by dehydration, excessive sodium intake, or kidney dysfunction. It is not related to Addison’s disease or cortisol and aldosterone levels.
Choice B: Bradycardia. This is not a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease. Bradycardia is a slow heart rate, which can be caused by vagal stimulation, medication side effects, or cardiac disorders. It is not related to Addison’s disease or cortisol and aldosterone levels.
Choice C: Hypotension. This is a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease, which is a condition that occurs when the adrenal glands do not produce enough cortisol and aldosterone. Cortisol is a hormone that regulates the metabolism of carbohydrates, proteins, and fats, and helps the body cope with stress. Aldosterone is a hormone that regulates the balance of sodium and potassium in the blood and fluid volume. Addison’s disease can cause hypotension, which is a low blood pressure, due to decreased aldosterone production and fluid loss.
Choice D: Hypokalemia. This is not a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease. Hypokalemia is a low level of potassium in the blood, which can be caused by diuretics, vomiting, diarrhea, or alkalosis. It is not related to Addison’s disease or cortisol and aldosterone levels.
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