A nurse is planning care for a client who has manifestations of a Clostridium difficile (C. difficile) infection. Which action should the nurse plan to take?
Place a surgical mask on the client during transport.
Use gown and gloves when entering the room.
Use an alcohol-based agent to perform hand hygiene when caring for the client.
Obtain a blood specimen to test for C. difficile.
The Correct Answer is B
Choice A reason: Placing a surgical mask on the client during transport is not the primary precaution for C. difficile infections. C. difficile is primarily transmitted through contact with contaminated surfaces and not through respiratory droplets. Therefore, while masks may be used for other infections, they are not the main precaution for C. difficile.
Choice B reason: Using gown and gloves when entering the room is essential for preventing the spread of C. difficile. This infection is highly contagious and can be transmitted through contact with contaminated surfaces or feces. Gown and gloves provide a barrier that helps prevent the transmission of the bacteria to healthcare workers and other patients.
Choice C reason: Using an alcohol-based agent to perform hand hygiene is not effective against C. difficile spores. Hand washing with soap and water is recommended because it is more effective at removing the spores from the hands. Alcohol-based hand sanitizers do not kill C. difficile spores and should not be relied upon for hand hygiene in this context.
Choice D reason: Obtaining a blood specimen to test for C. difficile is not the standard diagnostic method. C. difficile infections are typically diagnosed through stool tests that detect the presence of the bacteria or its toxins. Blood tests are not used for diagnosing C. difficile infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Cranial nerve V is the trigeminal nerve, which has both motor and sensory functions:Motor function: The nurse can assess this by asking the client to clench their teeth while palpating the masseter and temporalis muscles for strength.Sensory function: The nurse can assess this by lightly touching the client's face in different areas (forehead, cheeks, and jaw) with a cotton ball or sharp/dull object to check for sensation.
Choice B Reason:
Asking the client to identify scented aromas is a method used to assess cranial nerve I (Olfactory), not cranial nerve V. Cranial nerve V (Trigeminal) is assessed by testing facial sensation and motor functions such as chewing.
Choice C Reason:
Asking the client to read a Snellen chart is a method used to assess cranial nerve II (Optic), which is responsible for vision. This method does not assess cranial nerve V
Choice D Reason:
Asking the client to raise his eyebrows is a method used to assess cranial nerve VII (Facial), which controls facial expressions. This method is not used to assess cranial nerve V.
Correct Answer is C
Explanation
Choice A Reason:
The gastrocnemius muscle, located in the calf, is not a recommended site for intramuscular injections in newborns. This muscle is not typically used due to its small size and the difficulty in accessing it safely for an injection.
Choice B Reason:
The dorsogluteal muscle, located in the buttocks, is also not recommended for newborns. This site is avoided because of the risk of damaging the sciatic nerve and the relatively thick layer of subcutaneous fat, which can interfere with the absorption of the medication.
Choice C Reason:
The vastus lateralis muscle, located in the thigh, is the preferred site for intramuscular injections in newborns. This muscle is well-developed at birth and provides a large, easily accessible area for injections. It is also away from major blood vessels and nerves, making it a safe and effective site for administering medications like vitamin K.
Choice D Reason:
The ventrogluteal muscle, located on the side of the hip, is another site used for intramuscular injections, but it is not typically recommended for newborns. This site is more commonly used in older children and adults due to its deeper location and the need for precise anatomical knowledge to avoid complications.
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