NCLEX-RN
Fundamentals of Nursing NCLEX RN Questions Questions
Extract:
The following scenario applies to the next 1 items
Item 1 of 1
Nurses' Notes
Orders Current Medications Laboratory>
1700: 73-year-old male reports explosive, watery, foul-smelling diarrhea that started two days ago. The client reports intermittent abdominal cramping that occurs with watery diarrhea. He says his wife made him come in to get medical attention because he was starting to 'feel weak' and 'probably dehydrated.' The client was assessed to have: a sunken eye appearance, dry, flaky skin, and thready peripheral pulses. VS: Oral Temperature 98° F (36.7° C), pulse 86/minute, respirations 16/minute, blood pressure 113/68 mm Hg, oxygen saturation 96% on room air.
1725: Stool sample of foul-smelling diarrhea sent to the lab.
1830: Laboratory result received. Physician notified of results.
Question 1 of 5
The nurse reviews the nurses' notes, orders, current medications, and laboratory data for a 73-year-old male with explosive, watery, foul-smelling diarrhea. Based on the clinical data, select five (5) nursing interventions the nurse should implement.
| Obtain a prescription for metronidazole |
| Place a droplet precautions sign outside the room |
| Educate the client to wash surfaces at home with bleach |
| Remove the alcohol-based sanitizers from the room |
| Request a prescription for a cleansing enema |
| Encourage the intake of by mouth (PO) fluids |
| Review hand hygiene measures with the client |
Correct Answer: A,C,D,F,G
Rationale: Suspected C. difficile requires metronidazole, bleach cleaning, removal of alcohol-based sanitizers, fluid intake encouragement, and hand hygiene education. Droplet precautions and enemas are not indicated.
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