Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a 2-year-old child who has Clostridium difficile.
Which of the following actions should the nurse take?
A. Use an N95 respirator.
Is not necessary for the care of a child with Clostridium difficile. Respirators are typically used for airborne precautions, which are not indicated for this specific infection.
B. Instruct the parents to avoid bringing fresh flowers into the room.
Is not specific to the care of a child with Clostridium difficile. While it is generally recommended to minimize potential sources of contamination in healthcare settings, this particular instruction is not specific to this infection.
C. Initiate contact precautions.
Clostridium difficile is a bacterium that causes diarrhea and can be easily transmitted from person to person. Contact precautions are necessary to prevent the spread of the infection. This includes wearing gloves and a gown when providing direct care to the child, ensuring proper hand hygiene, and implementing proper disinfection protocols for the environment.
D. Place the child in a room that has a HEPA filtration system.
Is not necessary for the care of a child with Clostridium difficile. HEPA filtration systems are typically used for airborne precautions, which are not indicated for this specific infection.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Comprehensive Predictor 2023 - Proctored Exam 1. Take the full exam now
Full Explanation
Explanation
C. Initiate contact precautions
Clostridium difficile is a bacterium that causes diarrhea and can be easily transmitted from person to person. Contact precautions are necessary to prevent the spread of the infection. This includes wearing gloves and a gown when providing direct care to the child, ensuring proper hand hygiene, and implementing proper disinfection protocols for the environment.
The other options are not necessary or specific to the care of a child with Clostridium difficile:
Using an N95 respirator in (option A) is not necessary for the care of a child with Clostridium difficile. Respirators are typically used for airborne precautions, which are not indicated for this specific infection.
Instructing the parents to avoid bringing fresh flowers into the room in (option)is not specific to the care of a child with Clostridium difficile. While it is generally recommended to minimize potential sources of contamination in healthcare settings, this particular instruction is not specific to this infection.
Placing the child in a room with a HEPA filtration system in (option D) is not necessary for the care of a child with Clostridium difficile. HEPA filtration systems are typically used for airborne precautions, which are not indicated for this specific infection.
Similar Questions
A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. For which of the following actions by the AP should the nurse intervene?
A. Locks the wheels on the client's bed
Locking the wheels on the client's bed: This is an appropriate action to prevent the bed from rolling and ensures stability.
B. Clears furniture from the path leading to the bathroom
Clearing furniture from the path leading to the bathroom: This is a good practice as it creates a clear and safe path for the client to walk without obstacles.
C. Assists the client to the bathroom every 2 hr
Assisting the client to the bathroom every 2 hours: This is a proactive measure to prevent falls by ensuring regular toileting and minimizing the need for the client to get up and move independently. It's important to promote mobility and independence for the client while ensuring their safety.
D. Raises all four side-rails on the client's bed
The nurse should intervene when the AP raises all four side-rails on the client's bed. While it is important to ensure the client's safety and minimize the risk of falls, raising all four side-rails can be considered a restraint and may not be the best practice for fall prevention. The use of physical restraints, including all four side-rails, can lead to adverse outcomes such as entrapment, increased agitation, and decreased mobility.
Full Explanation
The nurse should intervene when the AP raises all four side-rails on the client's bed. While it is important to ensure the client's safety and minimize the risk of falls, raising all four side-rails can be considered a restraint and may not be the best practice for fall prevention. The use of physical restraints, including all four side-rails, can lead to adverse outcomes such as entrapment, increased agitation, and decreased mobility.
Locking the wheels on the client's bed: This is an appropriate action to prevent the bed from rolling and ensures stability.
Clearing furniture from the path leading to the bathroom: This is a good practice as it creates a clear and safe path for the client to walk without obstacles.
Assisting the client to the bathroom every 2 hours: This is a proactive measure to prevent falls by ensuring regular toileting and minimizing the need for the client to get up and move independently.
It's important to promote mobility and independence for the client while ensuring their safety.
A nurse is reviewing laboratory findings for three clients.
Which of the following laboratory results should the nurse expect for a client who has cirrhosis?
A. Elevated amylase
It is typically seen in conditions affecting the pancreas, such as pancreatitis, and is not specific to cirrhosis.
B. Decreased bilirubin
They are not expected in cirrhosis. In fact, bilirubin levels are often elevated in cirrhosis due to impaired liver function and the accumulation of bilirubin in the blood.
C. Elevated lipase
It is typically seen in pancreatic disorders, such as pancreatitis, and is not specific to cirrhosis.
D. Elevated ammonia
Cirrhosis is a chronic liver disease characterized by the progressive scarring of liver tissue. As liver function becomes impaired, there is a decrease in the liver's ability to metabolize and detoxify substances, including ammonia. Elevated ammonia levels in the blood, known as hyperammonemia, are commonly seen in clients with advanced cirrhosis.
Full Explanation
Explanation
D, Elevated ammonia
Cirrhosis is a chronic liver disease characterized by the progressive scarring of liver tissue. As liver function becomes impaired, there is a decrease in the liver's ability to metabolize and detoxify substances, including ammonia. Elevated ammonia levels in the blood, known as hyperammonemia, are commonly seen in clients with advanced cirrhosis.
Elevated amylase in (option A) is incorrect because it is typically seen in conditions affecting the pancreas, such as pancreatitis, and is not specific to cirrhosis.
Decreased bilirubin levels in (option B) is incorrect because they are not expected in cirrhosis. In fact, bilirubin levels are often elevated in cirrhosis due to impaired liver function and the accumulation of bilirubin in the blood.
Elevated lipase in (option C) is incorrect because it is typically seen in pancreatic disorders, such as pancreatitis, and is not specific to cirrhosis.
A community health nurse is developing a brochure about hypertension.
Which of the following actions should the nurse take?
A. Write the information at an 8th-grade reading level.
Writing the information at an 8th-grade reading level ensures that it is accessible and understandable to a wide range of individuals in the community. Hypertension is a common health condition, and it is important to provide information in a clear and concise manner that can be easily comprehended by the target audience.
B. Explain medical terminology using basic, one-syllable words.
Is not recommendable because it may oversimplify the information and potentially undermine the importance of accuracy and precision in healthcare communication.
C. Use a 12-point font size.
It is a general guideline for readability, but it is not the most critical aspect when developing a brochure. The readability of the content itself is more important than the specific font size.
D. Present information from complex to simple.
Is not recommendable because it is not the most effective approach when developing a brochure about hypertension. It is more beneficial to present information in a simple and straightforward manner from the beginning to enhance understanding and engagement.
Full Explanation
Explanation
A. Write the information at an 8 th grade reading level
Writing the information at an 8th-grade reading level ensures that it is accessible and understandable to a wide range of individuals in the community. Hypertension is a common health condition, and it is important to provide information in a clear and concise manner that can be easily comprehended by the target audience.
Explaining medical terminology using basic, one-syllable in words in (option B) is not recommendable because it may oversimplify the information and potentially undermine the importance of accuracy and precision in healthcare communication.
Using a 12-point font size in (option C) is not recommendable because it is a general guideline for readability, but it is not the most critical aspect when developing a brochure. The readability of the content itself is more important than the specific font size.
D. Presenting information from complex to simple in (option D) is not recommendable because it is not the most effective approach when developing a brochure about hypertension. It is more beneficial to present information in a simple and straightforward manner from the beginning to enhance understanding and engagement.
Therefore, the nurse should write the information at an 8th-grade reading level (option A) to ensure that it is easily accessible and comprehensible for the target audience.