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A nurse is caring for a toddler whose guardian reports multiple episodes of diarrhea. The provider suspects Clostridium difficile. Which of the following actions should the nurse take?

Collect a stool specimen for occult blood.

Conduct a tape test.

Obtain a stool specimen for culture.

Draw a blood culture.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Collecting a stool specimen for occult blood is not the most relevant test for suspected

Clostridium difficile infection. Stool culture or testing for C. difficile toxins is more appropriate.

Choice B reason:

Conducting a tape test is used to diagnose pinworms, not Clostridium difficile infection.

Choice C reason:

This statement is correct. Obtaining a stool specimen for culture, specifically for C. difficile, is the appropriate action for suspected infection.

Choice D reason:

Drawing a blood culture is not the primary diagnostic test for Clostridium difficile. Stool culture or testing for C. difficile toxins is more appropriate.

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Correct Answer is C

Explanation

Choice A reason:

A maculopapular rash may be an allergic reaction to the antibiotic. While this should be reported, wheezing is a more urgent concern.

Choice B reason:

A headache may be a side effect of the antibiotic, but it is not as urgent as wheezing.

Choice C reason:

Wheezing can indicate a potential serious allergic reaction or anaphylaxis to the antibiotic. This is the priority finding to report to the provider.

Choice D reason:

An increased pulse may be a side effect of the antibiotic, but it is not as urgent as wheezing.

A. Suction the client's airway every 2 hr. B. Maintain the client's head of the bed at 30°. C. Keep the client's room well lit. D. Check the client's temperature every 8 hr.

Correct Answer is B

Explanation

A: Suctioning the client's airway every 2 hours is not indicated based on the provided information. The adolescent does not have a condition that compromises airway clearance, and routine suctioning can cause trauma or stimulate a vagal response, potentially leading to bradycardia.

B: Maintaining the client's head of the bed at 30° is appropriate for reducing intracranial pressure and facilitating venous drainage. The patient's symptoms of nuchal rigidity and severe headache suggest increased intracranial pressure, possibly due to meningitis, which is supported by the diagnostic results.

C: Keeping the client's room well lit is not advisable as the patient reports photophobia, which is a sensitivity to light. A well-lit room could exacerbate discomfort and pain.

D: Checking the client's temperature every 8 hours is important but not the priority intervention. The patient's condition requires more frequent monitoring due to the positive blood culture and sensitivity, indicating an active infection. More frequent temperature checks would be warranted.

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A nurse is caring for a toddler whose guardian reports multiple episodes of diarrhea. The provider suspects Clostridium difficile. Which of the following actions should the nurse take?

Nursing Test Bank

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