a nurse is caring for a client who has c diff infection which of the following actions should the nurse take a nurse is caring for a client who has c diff infection which of the following actions should the nurse take
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HESI LPN

HESI Fundamentals Study Guide

1. A client has C-diff infection. Which of the following actions should the nurse take?

Correct answer: D

Rationale: The correct answer is to initiate contact precautions when providing client care. C-diff (Clostridium difficile) is highly contagious, and contact precautions are necessary to prevent its spread. Giving the client chlorhexidine gluconate for hand hygiene (Choice A) is not specific to managing C-diff. Removing the protective gown first when exiting the client's room (Choice B) may increase the risk of contaminating oneself and the environment. Using alcohol-based hand rub when caring for the client (Choice C) is not sufficient to prevent the transmission of C-diff, as soap and water are more effective against this particular pathogen.

2. A client had a mastectomy 6 months ago and expresses a decreased desire for sexual relations, stating “My body is so different now.” Which of the following responses should the nurse make?

Correct answer: B

Rationale: In this situation, the appropriate response is to reflect on the client’s feelings and explore their experience. Choice A may unintentionally dismiss the client's concerns by not addressing their emotional needs. Choice C suggests a spa treatment as a solution without addressing the underlying emotional issues. Choice D implies that the client's feelings will resolve with time, which may not be helpful in addressing the client's current emotional state.

3. What is the main purpose of the initial assessment of a child with a suspected fracture?

Correct answer: B

Rationale: The main purpose of the initial assessment of a child with a suspected fracture is to check for potential complications, such as neurovascular impairment, and to ensure appropriate treatment. Choice A is incorrect because determining the type of fracture usually requires imaging studies like X-rays, which may not be part of the initial assessment. Choice C is incorrect because identifying the cause of the injury is important for the history-taking part but may not be the main purpose of the initial assessment. Choice D is incorrect because long-term rehabilitation planning typically occurs after the acute phase of fracture management.

4. A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin sodium at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 units in 5% Dextrose Injection 250 ml. The nurse should program the infusion pump to deliver how many ml/hour?

Correct answer: B

Rationale: To calculate the infusion rate, first, find the total dose required per hour, which is the patient's weight (220 pounds) multiplied by the prescribed rate (18 units/kg/hour). This equals 3960 units/hour. Next, determine how many ml of the solution contain 25,000 units; this is 250 ml. Divide the total dose required per hour (3960 units) by the units per ml (25,000 units/250 ml) to find how many ml are needed per hour. This results in 27 ml/hour. Therefore, the nurse should program the infusion pump to deliver 27 ml/hour. Choice A (18) is incorrect as it does not account for the concentration of the heparin solution. Choices C (36) and D (45) are incorrect as they do not reflect the accurate calculations based on the patient's weight and the heparin concentration in the solution.

5. What is the term for the study of how diet affects gene expression?

Correct answer: B

Rationale: Nutrigenomics is the study of how diet affects gene expression, influencing health outcomes and disease risk. Epigenetics (choice A) involves changes in gene expression or cellular phenotype caused by mechanisms other than changes in the underlying DNA sequence. Genomics (choice C) is the study of an organism's entire genome. Genetics (choice D) is the study of heredity and the variation of inherited characteristics.

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