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 D

Explanation

A. Tinnitus with ear pain: While tinnitus can be a side effect of some medications, it is not associated with Stevens-Johnson syndrome (SJS). This symptom is more common with other medications or conditions, like aspirin or certain antibiotics, but not allopurinol.

B. Diplopia: Diplopia (double vision) is not a common sign of Stevens-Johnson syndrome. This symptom could be related to other conditions but is not characteristic of SJS.

C. Hyperreflexia: Hyperreflexia is not a typical manifestation of Stevens-Johnson syndrome. While neurological symptoms may sometimes occur, they are not central to the diagnosis of SJS.

D. Skin rash with fever: A skin rash with fever is a classic early sign of Stevens-Johnson syndrome. It is a potentially life-threatening reaction to certain medications, including allopurinol, and requires immediate medical attention. The rash often begins with a mild erythema, which may progress to blistering and sloughing of the skin.

A. Platelet count B. Sputum color C. Temperature D. Fluid intake

Correct Answer is C

Explanation

A. Platelet count is normal (175,000/mm3) and does not require reporting to the provider.

B. Sputum color: While thick green sputum might suggest infection, the nurse should first assess for other clinical signs, and it might not need immediate reporting unless there are other concerns, like a change in respiratory status.

C. Temperature (38°C / 100.4°F) is elevated, which could indicate an infection, such as a respiratory infection or exacerbation of COPD. This finding should be reported to the provider because fever in a client with COPD could lead to complications like pneumonia or exacerbation of symptoms.

D. Fluid intake of 2,200 mL/24 hr is within normal limits and does not need reporting.

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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 reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?

Correct Answer is D

Explanation

Exhibits A nurse is reviewing the medical record of a client who has COPD. Which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Correct Answer is C

Explanation

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