A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which of the following actions should the nurse plan to take?

Use an alcohol-based agent to perform hand hygiene when caring for the client.

Obtain a blood specimen to test for C. difficile.

Place the client on contact precautions.

Place a surgical mask on the client during transport.

Answer and Explanation

The Correct Answer is C

A. Alcohol-based hand sanitizers are not effective against C. difficile spores; hand hygiene should be performed using soap and water to effectively remove the spores.

B. Testing for C. difficile typically involves stool samples, not blood specimens, making this option inappropriate for confirming the infection.

C. Placing the client on contact precautions is essential to prevent the spread of C. difficile, as it is highly contagious and can be transmitted via surfaces and direct contact.

D. A surgical mask is not necessary for clients with C. difficile unless they have respiratory symptoms; the primary concern is preventing contact transmission.

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Correct Answer is C

Explanation

A. Performing the final medication check in the area where the medication was obtained does not ensure the correct patient is receiving the medication.

B. Documenting after administration does not allow for a final check of the medication against the patient’s identity and allergies.

C. Performing the final check at the client's bedside before administration allows the nurse to confirm the patient's identity, the medication's appropriateness, and the dosage immediately before giving it.

D. Reviewing the prescription at the nurses' station may not account for patient-specific factors that need to be confirmed at the bedside.

A. Urine is cloudy after sitting in the urinal for 6 hours. B. First-voided urine in the morning has a strong odor. C. Urine output of 175 mL in the past 8 hours. D. Urine output of 2,200 mL in the past 24 hours.

Correct Answer is C

Explanation

A. Cloudy urine may indicate sediment or the presence of protein but does not necessarily require immediate notification to the provider.

B. A strong odor in the first-voided urine can be normal or due to dehydration or dietary factors, and does not immediately warrant concern.

C. A urine output of 175 mL in 8 hours is significantly low and indicates possible oliguria, which is a concern for impaired renal function and should be reported to the provider.

D. A urine output of 2,200 mL in 24 hours can indicate normal or excessive output (polyuria), but it is less concerning than oliguria and does not require immediate notification.

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A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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