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The nurse is caring for a client who is receiving antibiotic therapy and develops Clostridioides difficile colitis. Which of the following infection-control precautions should the nurse implement? Select all that apply.
- A. Disinfect surfaces using a diluted bleach solution
- B. Perform hand hygiene using an alcohol-based hand sanitizer
- C. Wear a face mask
- D. Wear a protective gown
- E. Wear nonsterile gloves
Correct Answer: A,D,E
Rationale: Bleach disinfection (A), gowns (D), and gloves (E) are required for C. difficile, which is spore-forming. Alcohol sanitizers (B) are ineffective against spores, and masks (C) are not routinely needed.
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The nurse is planning an approach to decrease urinary incontinence in an elderly client. Which activity will do the most to help prevent incontinence?
- A. Restrict fluids until continence has been achieved and then hydrate well.
- B. Offer the bedpan at two-hour intervals during the day and every four hours at night.
- C. Encourage the client to ambulate frequently and have the client do deep breathing exercises.
- D. Encourage fluids during the day and offer the bedpan every two hours.
Correct Answer: D
Rationale: Adequate hydration and frequent toileting (every two hours) promote bladder health and reduce incontinence. Fluid restriction or unrelated exercises are ineffective.
The nurse is caring for all of the following persons. Which one is most in need of restraints?
- A. An elderly man who is sitting in a chair
- B. A confused postoperative client who is picking at his nasal oxygen and nasogastric (NG) tube
- C. A confused woman who is in bed with the side rails up
- D. An adult who has just returned to the surgical floor from a postanesthesia care unit
Correct Answer: B
Rationale: The confused postoperative client risks dislodging critical tubes, necessitating restraints if non-restraint interventions fail. Others pose lower immediate risk.
The nurse assists with data collection during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer? Select all that apply.
- A. A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week.
- B. I am proud that I was able to lose 10 lb, but I'm still considered obese for my height.
- C. I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently.
- D. I have struggled with daily episodes of acid reflux for years, especially at nighttime.
- E. I snack on a lot of salted foods like popcorn and peanuts.
Correct Answer: A,C,D
Rationale: Smoking cigars (A), heavy alcohol use (C), and chronic acid reflux (D) are established risk factors for esophageal cancer. Obesity (B) is a weaker risk, and salted foods (E) are not directly linked.
The nurse is assessing a 7-year-old client who was recently admitted with nausea, vomiting, severe right lower quadrant pain, and an elevated WBC count. Which of the following statements by the client would be a priority to follow up?
- A. I feel so tired.
- B. I am hungry and I want to eat.
- C. My stomach does not hurt anymore.
- D. I do not like hospitals and I want to go home.
Correct Answer: C
Rationale: Resolution of pain (C) in suspected appendicitis may indicate perforation, a surgical emergency, requiring urgent follow-up. Fatigue (A), hunger (B), and dislike of hospitals (D) are less critical.
The nurse is caring for a 12-month-old client who is HIV-positive and severely immunosuppressed. Which of the following scheduled immunizations should the nurse anticipate administering to the client? Select all that apply.
- A. Haemophilus influenzae type b
- B. Hepatitis A
- C. Measles, mumps, rubella
- D. Pneumococcal conjugate vaccine
- E. Varicella
Correct Answer: A,D
Rationale: Hib (A) and PCV (D) are inactivated vaccines, safe for immunosuppressed children. MMR (C) and varicella (E) are live vaccines, contraindicated. Hepatitis A (B) is not routine at 12 months.