A nurse is collecting data from a client who has obstruction and inflammation of the common bile duct due to cholelithiasis. Which of the following findings is expected for this condition?

Choice A: Implement neutropenia isolation. This is not an action that the nurse should take for a client who has developed a Clostridium difficile infection. Neutropenia isolation is a type of protective isolation that is used for

clients who have low white blood cell counts and are at risk of infection from others. It is not indicated for clients who have Clostridium difficile infection, which is not transmited through the air.

Choice B: Use alcohol hand sanitizer following client care. This is not an action that the nurse should take for a client who has developed a Clostridium difficile infection. Alcohol hand sanitizer is ineffective against Clostridium difficile spores and can increase the risk of transmission. The nurse should wash their hands with soap and water, which can remove the spores from the skin.

Choice C: Monitor the client for manifestations of fluid overload. This is not an action that the nurse should take for a client who has developed a Clostridium difficile infection. Fluid overload is a condition that occurs when the body retains excess fluid and causes symptoms such as edema, dyspnea, and hypertension. It is not related to Clostridium difficile infection, which can cause fluid loss due to diarrhea and dehydration. The nurse should monitor the client for manifestations of fluid deficit, such as dry mucous membranes, tachycardia, and hypotension.

Choice D: Disinfect equipment with bleach solution. This is an action that the nurse should take for a client who has developed a Clostridium difficile infection, which is a bacterial infection that causes severe diarrhea and inflammation of the colon. Clostridium difficile spores are resistant to most disinfectants and can survive on surfaces for a long time. The nurse should disinfect equipment with bleach solution, which can kill the spores and prevent transmission.

Choice A: “Monitor blood glucose levels every 4 hours.” This is the priority action for the nurse to recommend to the client because it will help them detect and prevent hyperglycemia or hypoglycemia, which can lead to serious complications such as diabetic ketoacidosis or cerebral edema.

Choice B: “Consume 15 grams of carbohydrates every 1 to 2 hours.” This is an important action for the nurse to recommend to the client, but not the priority. The client should consume carbohydrates to prevent hypoglycemia, especially if they have nausea, vomiting, or diarrhea, but this should be done after monitoring their blood glucose levels.

Choice C: “Drink 8 ounces of fluid every hour while awake.” This is a necessary action for the nurse to recommend to the client, but not the priority. The client should drink fluids to prevent dehydration and electrolyte imbalance, which can worsen hyperglycemia, but this should be done after monitoring their blood glucose levels.

Choice D: “Take the usual dosage of insulin.” This is a required action for the nurse to recommend to the client, but not the priority. The client should take their insulin as prescribed to control their blood glucose levels, but this should be done after monitoring their blood glucose levels and adjusting the dosage if needed.