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

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

Use an N95 respirator.

Initiate contact precautions.

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

Answer and Explanation

The Correct Answer is C

A. Avoiding fresh flowers in the room is unnecessary for a child with Clostridium difficile. Fresh flowers are typically restricted for clients who are immunocompromised, such as those undergoing chemotherapy or organ transplants, rather than those with infectious diarrhea.

B. Using an N95 respirator is incorrect. Clostridium difficile is transmitted via the fecal-oral route and requires contact precautions, not airborne precautions. An N95 mask is only required for airborne pathogens like tuberculosis or measles.

C. Initiating contact precautions is correct. Clostridium difficile is highly contagious and spreads through spores that can survive on surfaces. Contact precautions, including the use of gloves and gowns and proper hand hygiene with soap and water, help prevent transmission.

D. Placing the child in a room with a HEPA filtration system is unnecessary. HEPA filtration is used for airborne pathogens, whereas Clostridium difficile is spread via direct and indirect contact rather than through the air.

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Correct Answer is B

Explanation

A. This medication will increase the immunity of your newborn.: Vitamin K does not directly affect the immunity of a newborn. It plays a crucial role in blood clotting, not immune function.

B. This medication will decrease the risk of hemorrhage in your newborn.: Vitamin K is given to newborns to prevent bleeding or hemorrhagic disease, as newborns have low levels of vitamin K at birth, which is essential for clotting.

C. This medication will decrease the possibility of your newborn developing jaundice.: Vitamin K does not have a role in preventing jaundice, which is related to elevated bilirubin levels in the blood.

D. This medication will increase the absorption of nutrients in the intestines.: Vitamin K does not influence nutrient absorption in the intestines; it primarily supports blood clotting by helping in the synthesis of clotting factors.

A. Client-stated, "I lost my balance and fell when I got out of bed to go to the bathroom." B. "An incident report has been completed and sent to risk management." C. "The client fell because the assistive personnel did not place nonskid slippers on the client." D. "The client does not appear to have any injuries resulting from the fall."

Correct Answer is A

Explanation

A. Client-stated, "I lost my balance and fell when I got out of bed to go to the bathroom." This is the correct choice. The nurse should document the client's own account of the event in the medical record. It is important to accurately record the client's statement, as documentation should reflect the facts and avoid interpretation or assumptions.

B. "An incident report has been completed and sent to risk management." This statement should not be included in the client's medical record. Incident reports are separate from clinical documentation and are not part of the patient's permanent medical record.

C. "The client fell because the assistive personnel did not place nonskid slippers on the client." This statement makes an assumption about the cause of the fall and includes blame, which is inappropriate for medical documentation. Documentation should focus on objective observations and the client's statement, not assigning fault.

D. "The client does not appear to have any injuries resulting from the fall." While the nurse may assess the client for injuries, this statement should not be included unless it is confirmed and part of a thorough, objective assessment. It’s important to document specific findings (e.g., "No visible injuries noted").

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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 is preparing a vitamin K injection to give to a newborn. The newborn's mother questions the purpose of the medication. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

Correct Answer is A

Explanation

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