# A client is receiving oral vancomycin for a first episode of severe Clostridioides difficile infection. Review the trended data and answer the questions.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=568345&lang=en  
> language: en  
> subject: Standard/Transmission-Based Precautions/Surgical Asepsis  
> category: SIPC

## Question

A client is receiving oral vancomycin for a first episode of severe Clostridioides difficile infection. Review the trended data and answer the questions.

| Time | Data |
| --- | --- |
| Day 1 0800 | data: Temp 38.1°C, HR 96, BP 118/74, RR 18, SpO2 96% RA. WBC 13,200, Cr 1.4, Lactate 1.8. 4 diarrhea episodes. Abdomen soft, mildly distended. |
| Day 2 0800 | data: Temp 38.4°C, HR 104, BP 106/68, RR 20, SpO2 95% RA. WBC 15,800, Cr 1.7, Lactate 2.4. 7 diarrhea episodes. Abdomen distended, tympanic. |
| Day 3 0800 | data: Temp 38.8°C, HR 112, BP 98/60, RR 22, SpO2 94% RA. WBC 18,500, Cr 2.1, Lactate 3.2. 9 diarrhea episodes. Abdomen markedly distended, rebound tenderness. |
| Day 3 1200 | data: Temp 39.0°C, HR 118, BP 92/58, RR 24, SpO2 93% RA. WBC 19,200, Cr 2.3, Lactate 3.8. 10 diarrhea episodes. Abdomen rigid, no bowel sounds, guarding. |

Q1. Based on the trend, what is the priority action at Day 3 1200?

Request an infectious disease consult for antibiotic adjustment.
Administer acetaminophen for fever and encourage oral fluids.
Notify the provider immediately and prepare for escalation to surgical evaluation.
Continue oral vancomycin and reassess vital signs in 4 hours.

Q2. Which finding most strongly suggests the client has developed fulminant colitis?

Elevation in serum creatinine from 1.4 to 2.3 mg/dL.
Increase in stool frequency from 4 to 10 episodes per day.
Progression from abdominal distention to rigidity with absent bowel sounds.
Rise in white blood cell count from 13,200 to 19,200/mm3.

Q3. The client's lactate level has risen from 1.8 to 3.8 mmol/L. What is the best interpretation of this change?

It reflects dehydration from diarrhea and will correct with oral rehydration.
It indicates worsening tissue hypoperfusion and possible septic shock.
It is an expected response to antibiotic therapy and not concerning.
It suggests the client has developed acute kidney injury unrelated to infection.

## Explanation

The trend shows progressive worsening of C. difficile infection despite oral vancomycin, with rising WBC, creatinine, lactate, and new hemodynamic instability and abdominal rigidity. This suggests fulminant colitis with possible toxic megacolon or bowel perforation, requiring immediate escalation to the provider and surgical evaluation, not just continued monitoring or routine antibiotic adjustment.

## In-depth explanation

Quick answer
The client has fulminant C. difficile colitis with hemodynamic instability, rising lactate, and abdominal rigidity, indicating possible toxic megacolon or perforation. Immediate provider notification and escalation to surgical evaluation is the priority.

Why this is correct
Worsening vital signs, rising WBC and creatinine, and progression from distention to rigidity are red flags for fulminant colitis. Delaying escalation risks perforation, sepsis, and death.

Clinical picture
Fulminant C. difficile infection is defined by hypotension, shock, ileus, or megacolon. Abdominal rigidity and absent bowel sounds suggest impending perforation. Surgical consultation is indicated for severe complicated disease.

Memory hook
Remember the '3 Ds' of severe C. diff: Distention, Deteriorating vitals, and Drowsiness. Escalate immediately when these appear.

NCLEX decision rule
In severe C. difficile infection, lack of improvement after 3 days of appropriate therapy or any sign of hemodynamic instability or peritonitis warrants urgent provider notification and consideration of surgical evaluation.

Why the alternatives are wrong
Continuing current therapy and reassessing in 4 hours is unsafe because the client is deteriorating rapidly. Requesting an infectious disease consult without immediate provider notification delays critical intervention. Administering an antipyretic and encouraging oral fluids is insufficient for hypotension and possible perforation.

Sources
1NCSBN 2026 NCLEX-RN Test Plan
2CDC Clinical Guidance for C. diff Infection Prevention

## Clinical scenario

A 68-year-old client with hypertension and stage 2 chronic kidney disease was admitted 3 days ago with severe Clostridioides difficile infection after a course of ceftriaxone for pneumonia. The client is in a private room on contact precautions and is receiving oral vancomycin 125 mg four times daily. Baseline laboratory values on admission: white blood cell count 13,200/mm3 (reference 4,000–11,000), serum creatinine 1.4 mg/dL (reference 0.6–1.2), lactate 1.8 mmol/L (reference 0.5–2.2). Vital signs at 0800: temperature 38.1°C (100.6°F), heart rate 96 beats/min, blood pressure 118/74 mm Hg, respiratory rate 18 breaths/min, oxygen saturation 96% on room air. The client reports 4 episodes of watery diarrhea in the past 24 hours.

## Key concepts

- **Fulminant colitis** — A severe form of C. difficile infection characterized by hypotension, shock, ileus, or megacolon, often requiring surgical intervention.
- **Toxic megacolon** — Acute colonic dilation with systemic toxicity, a life-threatening complication of severe colitis that can lead to perforation.
- **Lactate** — A marker of tissue hypoperfusion; rising levels indicate worsening shock and inadequate oxygen delivery.

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