Place the client on contact precautions.

💊 The client has had several days of diarrhea while receiving antibiotic therapy, and now has abdominal cramping and pain with fever 38.9°C.

💊 These findings are highly suspicious for Clostridioides difficile infection, especially in someone with recent antibiotic use and loose stools.

💊 Standard precautions for suspected or confirmed C. diff include contact precautions: private room if possible, gown and gloves, and soap-and-water hand hygiene.

💊 Initiating contact precautions early helps prevent spread of spores to other clients and staff, even as stool studies or orders are pending.

💊 Therefore, the nurse should place the client on contact precautions based on current symptoms and risk factors.

Request a prescription for an antiemetic medication.

💊 The client has reported ongoing nausea (“I am just not hungry right now”) with poor dietary intake, which can lead to dehydration, weakness, and delayed recovery.

💊 Treating nausea with an antiemetic can help improve oral intake, hydration, and overall comfort.

💊 The client is already dealing with diarrhea and infection, so maintaining nutrition and fluid status is especially important.

💊 There is no contraindication given for antiemetic use in this scenario, and the provider has not yet addressed this symptom directly with a medication order.

💊 Therefore, it is appropriate for the nurse to request a prescription for an antiemetic to manage symptoms and support recovery.

Clarify the prescription for amoxicillin with the provider.

💊 The medical history clearly states the client is “Allergic to penicillin.”

💊 Amoxicillin is a penicillin-class antibiotic, so giving it to a penicillin-allergic patient can cause hypersensitivity reactions, including anaphylaxis.

💊 Even if the client has tolerated some doses already, the nurse must treat this as a serious safety issue and avoid assuming it is safe.

💊 The nurse’s role includes medication safety and verification, so any order that conflicts with a known allergy must be clarified before further doses are given.

💊 Therefore, the nurse should immediately clarify the amoxicillin prescription with the provider due to the documented penicillin allergy.

Recommend increasing the dose of metoprolol.

💊 Metoprolol is a beta-blocker used to manage hypertension or tachycardia, and the client’s vitals do not show uncontrolled cardiovascular problems.

💊 Blood pressures are around 110–112/60–66 mm Hg, and pulse rates are 70–72/min, which are within acceptable, stable ranges.

💊 Increasing the dose of metoprolol in a client with infection and diarrhea could risk causing hypotension or bradycardia, especially as illness progresses.

💊 There is no indication in the data (no uncontrolled hypertension, no tachycardia) that would justify increasing the dose.

💊 Therefore, the nurse should not recommend increasing metoprolol; this action is inappropriate based on current assessment findings.

Hold the dose of levothyroxine.

💊 Levothyroxine treats hypothyroidism and is a chronic maintenance medication that should typically be continued unless there is a clear contraindication.

💊 There is no evidence in the scenario of overdose, thyrotoxicosis, or any condition that would require holding levothyroxine.

💊 Stopping levothyroxine abruptly without reason can lead to worsening hypothyroid symptoms, including fatigue, bradycardia, and slowed metabolism.

💊 Even in acute illness, many chronic medications like levothyroxine are continued unless specifically held by the provider.

💊 Therefore, the nurse should not hold levothyroxine based on the available information.

Ensure the client wears a surgical mask when they are outside of their room.

💊 Surgical masks for clients outside their room are mainly indicated for droplet or airborne respiratory infections (e.g., influenza, TB), not for UTI or C. diff diarrhea.

💊 This client’s issue is a UTI with possible antibiotic-associated diarrhea/C. diff, which requires contact precautions (gown, gloves, hand hygiene), not droplet isolation.

💊 There is no mention of cough, droplet-spread respiratory infection, or special respiratory isolation orders that would justify masking the client outside the room.

💊 The focus should be on contact precautions and environmental cleaning, not universal masking of the client.

💊 Therefore, having the client wear a surgical mask is not required for the current diagnoses and is not a priority action here.

When removing personal protective equipment, remove gloves first.

🦠 Gloves are the most contaminated piece of PPE because they directly touch the client, stool, sputum, and contaminated surfaces.

🦠 Removing gloves first reduces the chance of spreading organisms, especially C. difficile spores, to other parts of the PPE, the environment, or the nurse’s skin.

🦠 Standard PPE removal sequence typically begins with gloves, then face/eye protection, gown, and mask last, to reduce self-contamination.

🦠 With C. diff and influenza, meticulous removal of highly contaminated items (gloves) first is essential to controlling contact and droplet spread.

🦠 Therefore, removing gloves first is an appropriate and required part of correct isolation precautions for this client.

Don a gown when entering the client's room.

🦠 Clostridium difficile spreads via spores that contaminate stool, skin, and the environment, especially with diarrhea and frequent bathroom use.

🦠 Contact precautions for C. diff include the use of gown and gloves when entering the room, to prevent contamination of the nurse’s clothing and skin.

🦠 Because the client has diarrhea for several days and stool positive for C. diff, the risk of contact with contaminated surfaces is very high.

🦠 Wearing a gown helps prevent carrying spores on clothing to other patients, staff, or surfaces.

🦠 Thus, donning a gown when entering the client’s room is a correct and necessary isolation action.

Provide a mask for the client when they are outside their room.

🦠 The client’s sputum culture is positive for influenza, which is transmitted primarily via respiratory droplets produced by coughing, sneezing, and talking.

🦠 When the client leaves their room (e.g., for tests or procedures), they should wear a surgical mask to contain droplets and reduce the risk of infecting others.

🦠 This is a core element of droplet precautions, placing a barrier at the source (the client).

🦠 Staff and visitors may wear masks near the client, but it is equally important that the client wears a mask outside the room to minimize spread.

🦠 Therefore, providing a mask for the client when outside their room is a correct part of isolation precautions for influenza.

Perform hand hygiene with at least 4 to 5 mL of hand sanitizer when leaving the client's room.

🦠 Alcohol-based hand sanitizer is not effective against C. difficile spores, which have a protective coating that resists alcohol.

🦠 For clients with C. diff, guidelines require washing hands with soap and water, which physically removes spores via friction and rinsing.

🦠 Using only hand sanitizer after caring for this client could leave spores on the hands, allowing spread to other patients or surfaces.

🦠 While sanitizer is acceptable for many infections, it is not sufficient when caring for clients with spore-forming organisms like C. diff.

🦠 Therefore, this statement is incorrect—hand hygiene should be done with soap and water, not just alcohol sanitizer.

Place the client in a room with positive air flow.

🦠 A positive airflow room is designed so that air flows out of the room, protecting the client from outside contaminants; it is typically used for protective isolation, e.g., neutropenic clients.

🦠 For a client with C. diff and influenza, we are concerned about containing organisms, not pushing room air out into the hallway.

🦠 Influenza requires droplet precautions in a standard private room, and some respiratory pathogens require negative pressure, not positive.

🦠 Positive airflow could inadvertently increase the risk of spreading infectious particles into shared areas.

🦠 Thus, placing this client in a positive airflow room is not appropriate and not part of proper isolation precautions.

🩹 Fentanyl transdermal patches are designed to provide slow, continuous absorption of medication through the skin over 48–72 hours.

🩹 This means the client should be taught that pain relief is not immediate and that it can take several hours to reach a therapeutic level.

🩹 Understanding the slow onset helps prevent the client from expecting rapid relief and requesting unsafe additional opioids too soon.

🩹 The patch is intended for chronic, stable pain control, not sudden or breakthrough pain.

🩹 Therefore, teaching that the patch absorbs slowly to provide ongoing pain relief is accurate and essential.

"Cut the transdermal patch in half prior to application."

🩹 Transdermal patches should never be cut, because doing so disrupts the controlled-release mechanism and can cause unpredictable dosing.

🩹 Cutting the patch may lead to a rapid release of fentanyl, increasing the risk of overdose and respiratory depression.

🩹 Manufacturers design patches to deliver medication at a specific rate, which is only safe when the patch is kept intact.

🩹 If a lower dose is needed, the provider should prescribe a different patch strength, not have the nurse cut the patch.

🩹 Therefore, instructing the nurse to cut the patch in half is unsafe and incorrect.

"Record the date directly on the patch."

🩹 While some facilities allow labeling directly on the patch, many safety standards discourage writing on the patch itself because ink or pressure might damage the drug matrix.

🩹 Best practice is usually to document the date, time, and location in the medical record and sometimes on tape next to the patch, not on the patch surface.

🩹 Writing on the patch can potentially compromise the integrity of the delivery system.

🩹 NCLEX-style questions typically look for the safest, most conservative practice, which is to avoid altering the patch in any way.

🩹 So this is not the best instruction to include in general teaching.

"Keep the previous patch in place along with each new patch."

🩹 Leaving the old fentanyl patch in place while applying a new one would lead to double dosing, significantly increasing the risk of fentanyl toxicity and respiratory depression.

🩹 The old patch still contains residual medication, so it must be removed, folded, and discarded properly before a new patch is applied.

🩹 Safe practice requires only one fentanyl patch to be active on the body at a time, unless specifically ordered and carefully managed by a specialist (which is rare and not implied here).

🩹 This teaching would lead to serious medication errors and harm.

🩹 Therefore, it is clearly incorrect and unsafe.

🛏️ A slide board reduces friction between the client and surfaces, making transfers safer and easier for both the client and staff.

🛏️ Using two health care workers distributes the workload and reduces risk of musculoskeletal injury to staff.

🛏️ For an immobile, 230-lb client, mechanical aids and team assistance are considered best practice for safe handling.

🛏️ This method helps maintain spinal alignment and prevents shearing or dragging of the client.

🛏️ Therefore, this option reflects correct ergonomic and patient-safety technique for transfer.

Have the client roll onto a transfer board and pull the board onto the stretcher.

🛏️ An immobile client may not be able to actively roll or assist with the transfer, making this instruction unrealistic.

🛏️ Relying on the client to roll without proper staff support increases risk of injury to the client, especially post-op or with weakness.

🛏️ Also, “pull the board onto the stretcher” suggests that one person may be doing the work, which risks staff back strain.

🛏️ Safe transfer requires adequate staff help and stabilization of both client and board.

🛏️ Thus, while a transfer board can be useful, this description is incomplete and unsafe compared with the slide board + two workers option.

Move the client's upper body onto the stretcher first.

🛏️ Moving just the upper body first can cause twisting and misalignment of the spine and torso.

🛏️ This technique may lead to shearing forces on the skin and strain on the back and hips, especially in an immobile client.

🛏️ Proper transfer should move the client as a unit, not in segments, to protect both tissue integrity and comfort.

🛏️ It also increases risk of falls or sliding if the lower body remains unsupported.

🛏️ Therefore, this is not a safe or recommended transfer method.

Apply a transfer belt to the client prior to transferring to the stretcher.

🛏️ Transfer belts (gait belts) are used primarily for ambulatory or partially mobile clients, to provide a secure handhold while they stand and pivot.

🛏️ This client is described as immobile, which means they cannot safely assist with standing or moving with a belt.

🛏️ Using a belt in this situation does not address the need for lateral transfer and may give staff a false sense of security.

🛏️ The correct approach for an immobile client is the use of sliding or transfer devices and multiple staff, not gait belts.

🛏️ Thus, applying a transfer belt is not appropriate here.

💧 Normal urine output should be at least 30 mL/hr, which reflects adequate renal perfusion and fluid balance.

💧 25 mL/hr is below this threshold, raising concern for hypovolemia, decreased kidney perfusion, or possible acute kidney injury.

💧 In a post-op client, low urine output may indicate bleeding, dehydration, or shock, all of which are serious complications.

💧 This finding requires prompt assessment and possible provider notification.

💧 Therefore, 25 mL/hr urine output is a potential postoperative complication that must be recognized.

Hypoactive bowel sounds.

💧 After abdominal surgery, it is common and expected for bowel function to be slowed or hypoactive for the first 24–72 hours.

💧 Anesthesia, opioid use, and bowel manipulation all contribute to temporary decreased peristalsis.

💧 Hypoactive bowel sounds alone, at 24 hours post-op, are therefore considered a normal postoperative finding, not necessarily a complication.

💧 The nurse should still monitor for return of bowel function, but immediate alarm is not warranted solely from this finding.

💧 Thus, this is not the best indicator of a complication compared with low urine output.

Minimal amount of serosanguineous drainage on the abdominal dressing.

💧 A small amount of serosanguineous drainage is often expected after surgery, especially within the first 24 hours.

💧 The key concern would be if the drainage were excessive, bright red, or rapidly increasing, indicating active bleeding.

💧 Minimal drainage suggests the wound is relatively stable, and the dressing is functioning appropriately.

💧 This does not indicate wound dehiscence or hemorrhage at this point.

💧 Therefore, this is a normal postoperative finding, not a complication.

Temperature of 37.8° C (100.1° F).

💧 A mild low-grade temperature elevation (up to around 38° C / 100.4° F) in the first 24–48 hours post-op can be normal due to inflammatory response.

💧 It may reflect atelectasis or normal healing rather than frank infection.

💧 A more concerning fever pattern would be persistent temperatures over 38° C, or associated signs of infection at the wound, lungs, or urinary tract.

💧 At 37.8° C, this client’s temperature is only slightly elevated and not clearly indicative of a serious complication yet.

💧 Thus, it is less concerning than the subnormal urine output.

🌬️ For adult suctioning, safe suction pressure typically ranges around 100–150 mm Hg, and 120 mm Hg is within this recommended range.

🌬️ Using appropriate suction pressure helps remove secretions while minimizing mucosal trauma.

🌬️ Too high pressure can cause bleeding, irritation, and potential damage to the nasopharyngeal tissues.

🌬️ Proper suction setting is a key part of safe airway management.

🌬️ Therefore, setting the device to 120 mm Hg is an appropriate action.

Have the client tuck his chin to his chest during suctioning.

🌬️ Tucking the chin to the chest is more commonly used to protect the airway during swallowing, not for nasopharyngeal suctioning.

🌬️ For suctioning, the client’s head is generally kept in a neutral or slightly extended position to allow easier passage of the catheter.

🌬️ Chin-tucking may actually narrow the airway passage and make catheter insertion more difficult.

🌬️ This position does not enhance the effectiveness of nasopharyngeal suction.

🌬️ Thus, this is not the best action in this context.

Apply a petroleum-based lubricant to the catheter.

🌬️ For suctioning procedures, a water-soluble lubricant should be used, not a petroleum-based product.

🌬️ Petroleum-based lubricants can increase the risk of aspiration-related complications and are not safe for use in the respiratory tract.

🌬️ They may also interfere with certain respiratory equipment and are not recommended in airway procedures.

🌬️ Water-soluble lubricants are safer and easier to clear if small amounts enter the airway.

🌬️ Therefore, applying a petroleum-based lubricant is incorrect.

Apply suction to the catheter during insertion.

🌬️ Suction should never be applied during insertion because it can cause mucosal trauma and hypoxia.

🌬️ Standard practice is to insert the catheter without suction, then apply suction only while withdrawing the catheter, using a rotating motion.

🌬️ Applying suction on the way in can also pull tissue into the catheter opening, increasing injury risk.

🌬️ This also lengthens the time of continuous suction, worsening oxygen desaturation.

🌬️ Thus, applying suction during insertion is unsafe and incorrect.

❤️ This response uses therapeutic communication and respects the client’s autonomy and concerns.

❤️ It acknowledges that the client has a choice and offers to involve the provider in discussing alternatives (e.g., DOACs that require less monitoring).

❤️ The nurse is not dismissing the client’s fear of monitoring but instead is collaborating and empowering them.

❤️ It keeps the conversation open and nonjudgmental, which fosters trust.

❤️ Therefore, this is the best response among the options.

"Why don't you want to undergo monitoring?"

❤️ Asking “why” can feel confrontational or accusatory, making the client defensive.

❤️ This response focuses more on questioning the client’s resistance than on supporting and educating them.

❤️ Therapeutic communication favors open-ended questions that invite sharing, but without a blaming tone.

❤️ A better approach is to explore concerns by saying things like, “Tell me more about what worries you about monitoring,” rather than “why.”

❤️ Thus, this response is not ideal in terms of therapeutic communication.

"Regular monitoring is not difficult and will ensure that you remain healthy."

❤️ Although it contains accurate education about warfarin (which does require monitoring), it minimizes the client’s expressed reluctance.

❤️ It sounds somewhat reassuring but dismissive, not truly engaging with the client’s stated concern.

❤️ Effective therapeutic communication first acknowledges feelings and offers options, rather than simply telling the client it “won’t be difficult.”

❤️ The tone shifts toward persuasion rather than collaboration.

❤️ Therefore, this is not the best choice compared to offering a provider discussion of alternatives.

"Your provider wants you to take this medication."

❤️ This response appeals purely to authority and ignores the client’s autonomy and expressed fears.

❤️ It does not address the client’s concern about monitoring, nor does it provide education or options.

❤️ Statements like this can make the client feel pressured, which may harm the therapeutic relationship.

❤️ The nurse’s role is to advocate and facilitate understanding, not simply to reinforce orders without discussion.

❤️ Thus, this is not an appropriate therapeutic response.

🫁 In the postanesthesia period, the top priority is always airway and breathing; a respiratory rate of 10/min is below the normal range for adults (12–20/min).

🫁 This may indicate respiratory depression from anesthesia, opioids, or a combination, and can quickly lead to hypoventilation, CO₂ retention, and hypoxia.

🫁 If breathing becomes inadequate, even normal blood pressure and heart rate will not sustain oxygenation.

🫁 Early recognition of respiratory depression allows the nurse to stimulate the client, adjust opioids, or notify the provider for potential reversal.

🫁 Therefore, a RR of 10/min is the priority to communicate to the provider.

Heart rate 58/min.

🫁 A heart rate of 58/min is slightly bradycardic, but can be normal for some adults, especially if they are stable and asymptomatic.

🫁 In the absence of other serious cardiac symptoms (like hypotension, dizziness, or chest pain), a HR of 58 is less immediately life-threatening than respiratory depression.

🫁 The colon resection and anesthesia context make breathing issues more urgent.

🫁 While the provider should be aware of the heart rate, it is not the highest priority in this group of findings.

🫁 Thus, RR 10/min takes precedence over HR 58/min.

Temperature 35.8° C (96.4° F).

🫁 Mild hypothermia is a common finding in postoperative clients due to the cool OR environment and anesthesia effects.

🫁 Although it should be corrected (e.g., with warming blankets), it usually does not cause immediate life-threatening compromise like inadequate respirations.

🫁 Hypothermia can affect coagulation and healing, but it progresses more slowly than acute respiratory failure.

🫁 In the ABC priority framework, temperature is less urgent than respiratory rate.

🫁 Therefore, it is not the priority finding to report first.

Blood pressure 88/50 mm Hg.

🫁 A BP of 88/50 mm Hg indicates hypotension, which can be a sign of bleeding, hypovolemia, or anesthetic effect.

🫁 Hypotension is serious and requires prompt evaluation, but airway and breathing issues still come first in prioritization.

🫁 However, in many real-life scenarios, both RR 10 and BP 88/50 would be urgent; NCLEX-style questions emphasize ABCs → airway/breathing before circulation.

🫁 Once breathing issues are addressed, hypotension must be promptly managed.

🫁 For exam purposes, RR 10/min is considered the first priority.

📄 Informed consent requires that the client receive a clear explanation of the nature, risks, benefits, alternatives, and possible outcomes of a procedure.

📄 This detailed explanation must come from the provider who is performing the procedure, because they have the expertise and legal responsibility.

📄 The nurse’s role is usually to verify the client’s signature, assess their understanding, and witness that the consent was signed voluntarily.

📄 The nurse can reinforce teaching but does not independently obtain the informed consent for procedures.

📄 Therefore, stating that the provider performing the procedure is responsible is correct information.

The nurse's role is to provide the client with initial information about the procedure prior to obtaining informed consent.

📄 While nurses provide a lot of education and reinforcement, they do not replace the provider’s duty to explain the procedure fully.

📄 The “initial information” about the procedure’s nature, risks, and alternatives must come from the provider, not the nurse.

📄 If the nurse gives the primary explanation, it undermines the legal requirement that the performing provider obtain informed consent.

📄 The nurse may clarify or repeat information but cannot be the originator of procedural consent teaching.

📄 Thus, this statement misrepresents the nurse’s role and is incorrect.

Clients are unable to change their mind once a consent form is signed.

📄 Clients have the right to withdraw consent at any time, even after signing the form, as long as they are competent.

📄 Autonomy allows clients to refuse or stop a procedure, and care must then be adjusted accordingly.

📄 Implied “no turning back” after signing is incorrect and may coerce clients into continuing with something they no longer want.

📄 Informed consent is an ongoing process, not a one-time unchangeable event.

📄 Therefore, this statement directly violates client rights and autonomy.

The provider obtains verbal consent for the procedure without witnessing the client's signature.

📄 Informed consent typically requires a written, signed document for invasive procedures, and the provider must ensure it is properly completed and witnessed per policy.

📄 Simply obtaining verbal consent without witnessing the signature is not sufficient legal protection in most institutional policies.

📄 The provider is expected to both explain and ensure proper documentation of the client’s consent.

📄 The nurse often serves as the witness to the signature, verifying identity and voluntary agreement, but the provider must still be involved in the process.

📄 Thus, the idea that the provider can rely only on verbal consent and not witness or verify the form is incorrect.

🧩 An occupational therapist (OT) focuses on helping clients perform activities of daily living (ADLs) such as dressing, bathing, grooming, and feeding.

🧩 A client who has had bilateral knee replacement and now requires assistance with dressing is demonstrating difficulty with an ADL, not just ambulation.

🧩 The OT can assess for adaptive equipment (e.g., reacher, dressing stick, long-handled shoehorn) to promote independence and safety with dressing.

🧩 They also teach energy conservation and joint-protection techniques, which are crucial after joint surgery.

🧩 Therefore, the nurse should report these dressing-assistance needs to the occupational therapist, who specializes in ADL function.

Physical therapist

🧩 A physical therapist (PT) primarily focuses on mobility, such as gait training, transfers, strength, range of motion, and use of assistive devices like walkers or canes.

🧩 While the PT is very important after knee replacement surgery for walking and strengthening, they are not the primary specialist for dressing and other ADLs.

🧩 Dressing is classified as an occupational/ADL task, more aligned with OT scope.

🧩 PT may indirectly help by improving mobility, but the direct issue—needing help with dressing—should go to OT.

🧩 Thus, although PT will be involved in care, this specific information is better directed to the occupational therapist.

Respiratory therapist

🧩 A respiratory therapist (RT) is consulted for issues related to oxygenation, ventilation, breathing treatments, and airway management.

🧩 This client’s primary issue is functional independence with dressing; no respiratory problems are mentioned.

🧩 Reporting dressing-assistance needs to RT would not address the functional deficit.

🧩 RT might be involved if there were pulmonary complications (e.g., post-op atelectasis) but not for ADLs.

🧩 Therefore, this choice is not appropriate for the described concern.

Social worker

🧩 A social worker helps with discharge planning, community resources, financial and psychosocial support, and sometimes placement decisions.

🧩 They do not primarily train clients in ADLs like dressing, nor do they prescribe adaptive equipment.

🧩 While the social worker may eventually need to know about functional capacity for discharge planning, the therapeutic intervention for dressing difficulty comes from OT.

🧩 Social work involvement comes later, after therapy evaluations inform what support is needed at home or in rehab.

🧩 Therefore, the first person to report this to is not the social worker but the occupational therapist.