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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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A parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which of the following parameters is of most concern to the nurse?
- A. 50% increase in birth weight
- B. Head circumference greater than chest
- C. Crying when the parents leave
- D. Able to stand up briefly in play pen
Correct Answer: A
Rationale: 50% increase in birth weight. Birth weight should double by 6 months, indicating potential growth issues that require further evaluation.
The nurse is caring for a hospice client with advanced heart failure who is having trouble breathing. Which comfort intervention should the nurse implement first?
- A. Administer PRN albuterol by nebulizer
- B. Assist with guided imagery to relieve anxiety
- C. Elevate the head of the bed
- D. Give PRN sublingual morphine
Correct Answer: C
Rationale: Elevating the head of the bed (C) is the first non-pharmacologic intervention to ease breathing in heart failure by reducing pulmonary congestion. Albuterol (A) is for bronchospasm, imagery (B) is secondary, and morphine (D) is for severe distress.
An adult has been taking captopril (Capoten) for hypertension. The client tells the nurse that he has a dry cough and sometimes gets dizzy when he stands up. What conclusions should the nurse make regarding this client?
- A. The client is having severe side effects and should discontinue the drug until after he sees his physician.
- B. Dizziness is a common side effect of antihypertensives. The cough is probably unrelated to the medication.
- C. A dry cough is a common side effect of angiotensin-converting enzyme (ACE) inhibitors. The client should stand up slowly to avoid orthostatic hypotension, a common side effect of antihypertensives.
- D. Cough is a serious side effect and usually results in discontinuing the medication. The dizziness will get better with time.
Correct Answer: C
Rationale: Dry cough and orthostatic hypotension are common ACE inhibitor side effects; slow position changes mitigate dizziness, and cough may require evaluation.
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 is caring for an infant who has a prescription for amoxicillin 25 mg/kg/day in 2 divided doses. The client weighs 16.5 lb (7.5 kg). The nurse has amoxicillin oral suspension 125 mg/5 mL available. How many mL should the nurse administer to the client with each dose? Record your answer using 2 decimal places.
Correct Answer: 3.75 mL/dose
Rationale: Calculation: 7.5 kg × 25 mg/kg/day = 187.5 mg/day. Divided into 2 doses = 93.75 mg/dose. 125 mg/5 mL = 25 mg/mL. 93.75 mg ÷ 25 mg/mL = 3.75 mL/dose (A).