A nurse on a medical-surgical unit suspects that several patients have Clostridium difficile (C. difficile) when they all develop watery diarrhea.
What actions should the nurse plan to take while waiting for the patients’ lab results?
Request the providers to initiate antibiotic therapy for every patient on the unit.
Perform hand hygiene with an alcohol-based agent.
Obtain stool cultures from all patients on the nursing unit.
Place all patients who have symptoms on contact precautions.
The Correct Answer is D
Choice A rationale
Requesting the providers to initiate antibiotic therapy for every patient on the unit is not the most appropriate action. Antibiotics should only be used when there is a confirmed bacterial infection. Overuse of antibiotics can lead to antibiotic resistance and can potentially trigger C. difficile infection due to disruption of normal gut flora.
Choice B rationale
While performing hand hygiene with an alcohol-based agent is important in general infection control, it is not the most effective measure against C. difficile.
C. difficile spores are resistant to destruction by alcohol-based hand rubs. Therefore, hand hygiene for C. difficile should involve washing with soap and water.
Choice C rationale
Obtaining stool cultures from all patients on the nursing unit is not the most appropriate action. Stool cultures should be obtained from patients who are symptomatic. Testing asymptomatic patients can lead to false positives and unnecessary treatment.
Choice D rationale
Placing all patients who have symptoms on contact precautions is the correct answer. Contact precautions, including the use of gloves and gowns, can prevent the spread of C. difficile. This is because C. difficile is spread via the fecal-oral route, and its spores can survive on surfaces for long periods.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Hypotension: Frequent vomiting and diarrhea can cause dehydration, which can lead to hypotension.
B. Bradycardia: Bradycardia is not typically a symptom of dehydration caused by vomiting and diarrhea.
C. Pale yellow urine: Dehydration can cause urine to become concentrated, resulting in a darker color, not pale yellow.
D. Poor skin turgor: Dehydration can cause poor skin turgor, which is skin that lacks elasticity.
E. Flat neck veins: Dehydration can cause flat neck veins when the patient is lying supine.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Auscultating stomach sounds is an important step before administering a tube feeding. This helps to ensure that the gastrointestinal system is functioning properly and can handle the feeding.
Choice B rationale
Warming the formula to body temperature can help to increase the comfort of the client during the feeding. However, it is not a necessary step and can be skipped if the client does not have a preference.
Choice C rationale
Assisting the client to sit in an upright position is crucial before administering a tube feeding. This position reduces the risk of aspiration, which can occur if the formula enters the lungs.
Choice D rationale
Discarding residual gastric contents is not recommended. Instead, the nurse should check for residual before the feeding, and if the volume is above the predetermined threshold, the feeding should be delayed and the healthcare provider notified.
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