A nurse on a medical-surgical unit suspects that several patients have Clostridium difficile (C. difficile) when they all develop watery diarrhea.
What actions should the nurse plan to take while waiting for the patients’ lab results?
Request the providers to initiate antibiotic therapy for every patient on the unit.
Perform hand hygiene with an alcohol-based agent.
Obtain stool cultures from all patients on the nursing unit.
Place all patients who have symptoms on contact precautions.
The Correct Answer is D
Choice A rationale
Requesting the providers to initiate antibiotic therapy for every patient on the unit is not the most appropriate action. Antibiotics should only be used when there is a confirmed bacterial infection. Overuse of antibiotics can lead to antibiotic resistance and can potentially trigger C. difficile infection due to disruption of normal gut flora.
Choice B rationale
While performing hand hygiene with an alcohol-based agent is important in general infection control, it is not the most effective measure against C. difficile.
C. difficile spores are resistant to destruction by alcohol-based hand rubs. Therefore, hand hygiene for C. difficile should involve washing with soap and water.
Choice C rationale
Obtaining stool cultures from all patients on the nursing unit is not the most appropriate action. Stool cultures should be obtained from patients who are symptomatic. Testing asymptomatic patients can lead to false positives and unnecessary treatment.
Choice D rationale
Placing all patients who have symptoms on contact precautions is the correct answer. Contact precautions, including the use of gloves and gowns, can prevent the spread of C. difficile. This is because C. difficile is spread via the fecal-oral route, and its spores can survive on surfaces for long periods.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Step 1 is to interpret the laboratory values. The glucose level is within the normal range (7099 mg/dL). The chloride level is within the normal range (97-107 mEq/L). The sodium level is within the normal range (135-145 mEq/L). However, the potassium level is low (normal range is 3.5-5.0 mEq/L)89101112.
Step 2 is to plan the action based on the interpretation. Given the low potassium level, the nurse should plan to request a potassium replacement
Correct Answer is D
Explanation
Choice A rationale
While electrolyte balance is important in patient care, it is not the primary reason for measuring gastric residual before administering a feeding through an NG tube.
Choice B rationale
Confirming the placement of the NG tube is crucial before administering a feeding. However, measuring the gastric residual is not the primary method used to confirm tube placement.
Choice C rationale
Removing gastric acid that might cause dyspepsia is not the main purpose of measuring gastric residual. Dyspepsia, or indigestion, is typically managed with medications and dietary modifications.
Choice D rationale
The primary purpose of measuring gastric residual is to identify delayed gastric emptying. Gastric residual refers to the volume of formula or contents remaining in the stomach from the previous feeding. If gastric emptying is delayed, the nurse should avoid overfeeding the patient and causing gastric distention.
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