A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?

Use an N95 respirator.

Initiate contact precautions

Place the child in a room that has a HEPA filtration system.

Instruct the parents to avoid bringing fresh flowers into the room.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Use an N95 respirator: N95 respirators are necessary for airborne precautions, such as with tuberculosis or measles. C. difficile is transmitted via contact with contaminated surfaces or stool, not airborne particles, so an N95 is not indicated.

B. Initiate contact precautions: Contact precautions are required for C. difficile because it spreads through direct and indirect contact with contaminated surfaces or stool. Gloves and gowns should be worn, and hand hygiene with soap and water is essential to prevent spore transmission.

C. Place the child in a room that has a HEPA filtration system: HEPA filters are used for airborne pathogens or immunocompromised clients, not for enteric infections like C. difficile. This intervention would not reduce transmission risk in this case.

D. Instruct the parents to avoid bringing fresh flowers into the room: This precaution is typically for neutropenic or immunocompromised clients to reduce exposure to potential fungal spores. C. difficile precautions focus on containment of fecal-oral transmission routes, not environmental fungal sources.

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Correct Answer is D

Explanation

Rationale:

A. Shortness of breath when climbing stairs: Mild dyspnea is common in the third trimester due to the upward displacement of the diaphragm by the enlarging uterus. This is typically not a concerning sign unless it occurs at rest or is accompanied by other symptoms like chest pain.

B. Periodic numbness of the fingers: Numbness or tingling in the hands and fingers during pregnancy can be caused by carpal tunnel syndrome due to fluid retention. While uncomfortable, it is a benign and relatively common symptom that usually resolves postpartum.

C. Leukorrhea: Leukorrhea, or increased vaginal discharge, is a normal finding in late pregnancy. It helps prevent ascending infections and is only concerning if it becomes foul-smelling, itchy, or changes in color, which could indicate infection.

D. Blurred vision: Blurred vision during the third trimester can be a sign of pregnancy-induced hypertension or preeclampsia. It may indicate cerebral involvement or elevated blood pressure and requires immediate evaluation by the healthcare provider.

A. Apply a warm compress B. Stop the infusion. C. Document the infiltration. D. Elevate the arm.

Correct Answer is B

Explanation

Rationale:

A. Apply a warm compress: Applying a warm compress may help promote absorption of infiltrated fluid and reduce discomfort, but it should not be the initial action. Warm compresses are appropriate only after the infusion is stopped and proper assessment is completed.

B. Stop the infusion: The first priority when infiltration is suspected—evidenced by cool, edematous skin—is to stop the infusion immediately. Continuing the infusion could lead to worsening tissue damage or complications depending on the type of fluid or medication.

C. Document the infiltration: Documentation is necessary but not the immediate priority. It should follow prompt clinical action to stop the infusion and prevent further harm to the surrounding tissue.

D. Elevate the arm: Elevating the arm can help reduce edema, but this supportive measure should be done only after the infusion has been stopped. It does not address the root cause or prevent further infiltration.

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A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a provider's office is caring for a client who is in the third trimester of pregnancy. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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