A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which action should the nurse plan to take?
Place a surgical mask on the client during transport.
Use gown and gloves when entering the room.
Use an alcohol-based agent to perform hand hygiene when caring for the client.
Obtain a blood specimen to test for C. difficile.
The Correct Answer is B
Choice A reason: Placing a surgical mask on the client during transport is not the primary precaution for C. difficile infections. C. difficile is primarily transmitted through contact with contaminated surfaces and not through respiratory droplets. Therefore, while masks may be used for other infections, they are not the main precaution for C. difficile.
Choice B reason: Using gown and gloves when entering the room is essential for preventing the spread of C. difficile. This infection is highly contagious and can be transmitted through contact with contaminated surfaces or feces. Gown and gloves provide a barrier that helps prevent the transmission of the bacteria to healthcare workers and other patients.
Choice C reason: Using an alcohol-based agent to perform hand hygiene is not effective against C. difficile spores. Hand washing with soap and water is recommended because it is more effective at removing the spores from the hands. Alcohol-based hand sanitizers do not kill C. difficile spores and should not be relied upon for hand hygiene in this context.
Choice D reason: Obtaining a blood specimen to test for C. difficile is not the standard diagnostic method. C. difficile infections are typically diagnosed through stool tests that detect the presence of the bacteria or its toxins. Blood tests are not used for diagnosing C. difficile infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Fiber is correct. Fiber is essential for maintaining healthy bowel elimination. It helps to add bulk to the stool and promotes regular bowel movements. There are two types of fiber: soluble and insoluble. Soluble fiber absorbs water and forms a gel-like substance, which helps soften the stool and make it easier to pass. Insoluble fiber adds bulk to the stool and helps it move through the digestive tract more quickly.
Choice B Reason:
Fat is incorrect. While fats are an important part of a balanced diet, they do not play a primary role in maintaining healthy bowel elimination. Fats are essential for energy and the absorption of fat-soluble vitamins, but they do not have the same effect on bowel movements as fiber.
Choice C Reason:
Protein is incorrect. Protein is crucial for building and repairing tissues, but it does not directly influence bowel elimination. A diet high in protein without adequate fiber can sometimes lead to constipation.
Choice D Reason:
Minerals are incorrect. Minerals are vital for various bodily functions, including bone health, fluid balance, and muscle function. However, they do not directly impact bowel elimination in the same way that fiber does.
Correct Answer is A
Explanation
Choice A Reason:
Restlessness is often one of the earliest signs of hypoxia. When the body experiences low oxygen levels, the brain is one of the first organs to be affected. This can lead to symptoms such as anxiety, agitation, and restlessness as the brain struggles to function properly without adequate oxygen. These symptoms occur because the body is trying to compensate for the lack of oxygen by increasing respiratory and heart rates, which can make a person feel uneasy or restless.
Choice B Reason:
Cyanosis refers to a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. While cyanosis is a significant indicator of hypoxia, it is typically a later sign. By the time cyanosis is visible, hypoxia has usually been present for some time, and oxygen levels have been critically low. Therefore, it is not the earliest clinical manifestation of hypoxia.
Choice C Reason:
Apnea is the absence of breathing. This is a severe and late sign of hypoxia. When a person stops breathing, it indicates that the body has been deprived of oxygen for an extended period, leading to critical conditions. Apnea is a medical emergency and requires immediate intervention, but it is not an early sign of hypoxia.
Choice D Reason:
Bradycardia is a slower than normal heart rate. Like apnea, bradycardia is a late sign of hypoxia. Initially, the body responds to low oxygen levels by increasing the heart rate (tachycardia) to pump more oxygenated blood to tissues. Bradycardia occurs when the body can no longer compensate, and the heart rate slows down, indicating severe hypoxia and impending failure of the cardiovascular system.
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