Priority Decision: What is the most important thing the nurse should do when caring for a patient who has contracted Clostridium difficile?

Correct Answer: C

Rationale: The correct answer is C) Wear gloves and wash hands with soap and water. When caring for a patient with Clostridium difficile (C. diff), the most crucial aspect is to prevent the spread of the infection. C. diff is highly contagious and can be transmitted through spores that are resistant to many disinfectants. Wearing gloves and practicing proper hand hygiene with soap and water are essential to prevent the spread of the infection to other patients, healthcare workers, and the environment. Option A is incorrect because cleaning the entire room with ammonia is not the priority when caring for a patient with C. diff. While environmental cleaning is important, the immediate focus should be on preventing transmission through proper hand hygiene. Option B is incorrect because while probiotics may be beneficial in some cases to restore gut flora balance, it is not the priority when dealing with a C. diff infection. Option D is incorrect because alcohol-based hand sanitizers are not effective against C. diff spores. Washing hands with soap and water is necessary to mechanically remove the spores from the hands. In an educational context, it is crucial for nurses to understand the principles of infection control when caring for patients with infectious diseases like C. diff. Emphasizing the importance of proper hand hygiene, wearing appropriate personal protective equipment, and following standard precautions can help prevent the spread of infections in healthcare settings.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Obstructive jaundice with elevated unconjugated and conjugated bilirubin. When a patient has a biliary obstruction from gallstones, it leads to obstructive jaundice. The obstruction prevents the flow of bile into the intestine, causing a buildup of both unconjugated and conjugated bilirubin in the bloodstream. Option A) Hemolytic jaundice with normal conjugated bilirubin is incorrect because hemolytic jaundice results from increased breakdown of red blood cells and would typically have elevated unconjugated bilirubin levels. Option B) Posthepatic icteris with decreased unconjugated bilirubin is incorrect as posthepatic icterus, also known as obstructive jaundice, presents with elevated levels of both conjugated and unconjugated bilirubin due to impaired bile flow. Option D) Hepatocellular jaundice with altered conjugated bilirubin in severe disease is incorrect because hepatocellular jaundice is a result of liver cell damage, which would primarily affect conjugated bilirubin levels, not both forms as seen in obstructive jaundice. Understanding the different types of jaundice and their associated bilirubin patterns is crucial in the diagnosis and management of various gastrointestinal disorders. This knowledge is essential for nurses and healthcare providers to effectively care for patients with these conditions and to interpret laboratory results accurately.

Correct Answer: A

Rationale: In patients with cirrhosis, malnutrition is a common issue due to various factors like decreased appetite, altered metabolism, and nutrient malabsorption. The correct nursing intervention to improve nutrient intake in these patients is option A) Oral hygiene before meals and snacks. Rationale for Option A: Oral hygiene before meals and snacks is crucial in patients with cirrhosis because these individuals often suffer from complications like oral health problems, which can affect their ability to eat and digest food. By ensuring proper oral hygiene, such as brushing teeth and cleaning the mouth before meals, nurses can help improve the patient's appetite, taste perception, and overall willingness to eat. This intervention can enhance the patient's ability to consume essential nutrients, ultimately addressing the issue of malnutrition. Rationale for why the other options are incorrect: B) Providing all foods the patient likes to eat may not always be nutritionally adequate or appropriate for a patient with cirrhosis. While it is essential to consider the patient's food preferences, the focus should be on offering a well-balanced diet that meets their nutritional needs. C) Improving oral intake by feeding the patient is not a sustainable or empowering approach. Patients with cirrhosis should be encouraged to eat independently to maintain their dignity and autonomy. Nursing interventions should focus on supporting and facilitating the patient's ability to eat rather than feeding them. D) Limiting snack offers to when the patient is hungry does not address the underlying issues contributing to malnutrition in patients with cirrhosis. It is essential to provide regular, nutritious meals and snacks to ensure an adequate nutrient intake and prevent malnutrition. Educational context: Understanding and implementing appropriate nursing interventions for patients with cirrhosis is crucial for promoting optimal health outcomes. By prioritizing interventions like oral hygiene before meals and snacks, nurses can play a significant role in addressing malnutrition and supporting the nutritional needs of patients with gastrointestinal disorders. This rationale highlights the importance of evidence-based practice and individualized care in improving patient outcomes.

Correct Answer: A

Rationale: The correct answer is A) It is noninvasive and is a very reliable method of detecting gallstones. Rationale: Ultrasound of the gallbladder is a common diagnostic test for gallbladder disease because it is noninvasive, painless, and highly effective in identifying gallstones. It uses high-frequency sound waves to create images of the gallbladder, allowing healthcare providers to visualize the presence of stones. This method is preferred over other imaging techniques like CT scans or MRIs due to its accuracy and safety. Option B) is incorrect because ultrasound is not limited to cases where other tests are contraindicated. Option C) is incorrect as ultrasound primarily focuses on identifying gallstones rather than outlining the entire ductal system. Option D) is incorrect as ultrasound is used for direct visualization rather than assessing inflammation through liver function tests. Educational Context: Understanding the diagnostic procedures for gallbladder disease is crucial for nurses caring for patients with suspected conditions. Educating patients about the purpose, process, and benefits of ultrasound helps alleviate anxiety and promotes patient cooperation. Nurses play a key role in ensuring that patients are well-informed about their healthcare journey, including the rationale behind specific tests and procedures.

Correct Answer: C

Rationale: In this question, the correct answer is C) Ulcerative colitis. Ulcerative colitis is an inflammatory bowel disorder characterized by symptoms such as abdominal pain, bloody diarrhea, tenesmus (the feeling of needing to pass stools even when the bowels are empty), and weight loss. Crohn's disease (option A) is another type of inflammatory bowel disease, but it typically presents with symptoms such as abdominal pain, diarrhea, fatigue, and weight loss. Diverticulitis (option B) is the inflammation or infection of small pouches that can form in the digestive system, leading to symptoms like abdominal pain, fever, and changes in bowel habits. Appendicitis (option D) is the inflammation of the appendix and usually presents with symptoms such as sudden abdominal pain that starts near the belly button and moves to the lower right side, nausea, vomiting, and fever. In an educational context, understanding the differences between these gastrointestinal disorders is crucial for healthcare professionals, especially nurses preparing for the NCLEX exam. Recognizing the specific symptoms associated with each condition is essential for accurate diagnosis and appropriate treatment. This knowledge also helps in providing quality care to patients with gastrointestinal disorders and promoting positive health outcomes.