A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?
Place the client in a protective environment.
Clean surfaces with chlorhexidine.
Wash hands with alcohol-based hand rub.
Obtain a stool specimen with gloves.
The Correct Answer is A
Clostridium difficile is a spore-forming bacteria that can cause severe diarrhea and other gastrointestinal symptoms. It's highly contagious and can easily spread to other patients. Alcohol-based hand rubs are not effective against spores and should not be used for hand hygiene in this case. Chlorhexidine is also not sporicidal and should not be used for environmental cleaning. A protective environment is indicated for clients who are at risk of infection from others, not for clients who are infectious to others. Gloves are important for preventing the spread of infection, but they should be used in conjunction with other infection control measures, such as handwashing and protective isolation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The client has hypokalemia, which is a low level of potassium in the blood. Hypokalemia can cause cardiac arrhythmias, which can be life-threatening. The nurse should initiate cardiac monitoring first to assess the client's heart rhythm and rate, and intervene if any abnormalities are detected. Administering an IV potassium drip is an appropriate intervention for hypokalemia, but it is not the first priority. Listening to the client's bowel sounds and checking the client's hand grasps are also relevant assessments for hypokalemia, as it can cause decreased bowel motility and muscle weakness, but they are not as urgent as cardiac monitoring.
Correct Answer is B
Explanation
A 2-g sodium diet means limiting sodium intake to no more than 2000 mg per day. Sodium is found in salt and many processed foods, such as canned vegetables, soups, sauces, and baked goods. Sodium can cause fluid retention and worsen heart failure symptoms, such as shortness of breath, swelling, and fatigue. Therefore, the client should avoid adding salt or salt substitutes (such as baking soda) to their foods and choose fresh or frozen vegetables over canned ones. Lemon juice is a low-sodium alternative that can add flavor to foods without increasing sodium intake.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today