A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which of the following actions should the nurse plan to take?

Use an alcohol-based agent to perform hand hygiene when caring for the client.

Obtain a blood specimen to test for C. difficile.

Place the client on contact precautions.

Place a surgical mask on the client during transport.

Answer and Explanation

The Correct Answer is C

A. Alcohol-based hand sanitizers are not effective against C. difficile spores; hand hygiene should be performed using soap and water to effectively remove the spores.

B. Testing for C. difficile typically involves stool samples, not blood specimens, making this option inappropriate for confirming the infection.

C. Placing the client on contact precautions is essential to prevent the spread of C. difficile, as it is highly contagious and can be transmitted via surfaces and direct contact.

D. A surgical mask is not necessary for clients with C. difficile unless they have respiratory symptoms; the primary concern is preventing contact transmission.

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Correct Answer is ["B","D","E"]

Explanation

A. Assessing the client every 4 hours is insufficient; the nurse should assess the client more frequently to monitor for changes in condition and risk factors for falls.

B. Placing a fall-risk identification band on the client's wrist is essential for alerting all staff to the client's fall risk, thereby promoting safety.

C. Keeping the client's room dark at night increases the risk of falls; adequate lighting should be provided to help the client navigate safely.

D. Teaching the client to use the call light encourages them to seek assistance when needed, which can help prevent falls.

E. Keeping the client's bed in the lowest position minimizes the risk of injury if the client attempts to get out of bed without assistance.

A. Check residual volume every 4 to 6 hr. B. Observe client's respiratory status. C. Elevate the head of the client's bed 30° to 45°. D. Monitor intake and output every 8 hr.

Correct Answer is C

Explanation

A. Checking residual volume is important for assessing tolerance to feedings, but it is not the priority action to prevent complications related to decreased consciousness.

B. Observing the client’s respiratory status is crucial but not the priority action related to enteral feedings.

C. Elevating the head of the client's bed 30° to 45° is the priority action, as it reduces the risk of aspiration during enteral feeding, which is a significant concern for clients with decreased consciousness.

D. Monitoring intake and output is important for overall assessment but is not the immediate priority in this context.

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A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select All that Apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is C

Explanation

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