# Stage 1 — Recognize cues. Review the 0800 nursing note. Highlight the findings that require the nurse's follow-up. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617300&lang=en > language: en > subject: Standard/Transmission-Based Precautions/Surgical Asepsis > category: SIPC ## Question Stage 1 — Recognize cues. Review the 0800 nursing note. Highlight the findings that require the nurse's follow-up. Hospital day 4, 0800. A 74-year-old client admitted with community-acquired pneumonia is receiving ceftriaxone and azithromycin; she took ciprofloxacin for a urinary tract infection two months ago. At home she lives alone, walks with a cane, and is continent. Since 0400 she has passed six watery stools with mild abdominal cramping and no visible blood. She has not received a laxative or stool softener in the past 48 hours. Yesterday she walked to the bathroom independently with her cane; she now asks for a bedpan because she feels unsafe walking and is lightheaded when she stands. Respiratory: cough with scant white sputum and fewer crackles than on admission; SpO2 96 percent on room air. Vital signs: temperature 37.9 C after 48 hours afebrile, heart rate 96, up from 74 yesterday, and BP 118/72, within her usual range. Laboratory: WBC 14.2, up from 9.1 x 10^9/L yesterday, with neutrophilia; procalcitonin down to 0.3 ng/mL from 1.8 on admission; creatinine 1.1 mg/dL (baseline 1.0); and lactate 1.4 mmol/L. She is alert and oriented times three. ## Explanation The new problem is abdominal, not pulmonary: six watery stools in four hours, a new low-grade temperature after 48 hours afebrile, a heart rate rising from 74 to 96, and a WBC that climbed from 9.1 to 14.2 while procalcitonin and crackles show the pneumonia is improving. Her request for a bedpan with lightheadedness on standing, when she walked to the bathroom independently yesterday, is a new fall and volume-loss cue. The chronic cane use, improving respiratory findings, and a normal lactate do not need action on their own. ## In-depth explanation Quick answer Highlight **six watery stools**, **feels unsafe walking**, **temperature 37.9 C**, **heart rate 96, up from 74**, and **WBC 14.2, up from 9.1**. Why this is correct Each correct cue is a change from this client's own recent baseline. The pneumonia is resolving (fewer crackles, scant sputum, procalcitonin falling from 1.8 to 0.3), so a new fever, rising heart rate, and a WBC that jumped overnight point to a new process. Combined with six watery stools after ceftriaxone, azithromycin, and recent ciprofloxacin, and no laxative in 48 hours, the pattern fits suspected C. difficile infection with early fluid loss. A client who walked independently yesterday but now feels unsafe walking and is lightheaded on standing has new orthostatic volume loss and fall risk that need an immediate safety plan. Easy analogy or mental picture Think of two dashboards: the lung dashboard is turning green, but the gut dashboard just lit up. The alarms that matter are the ones that changed since yesterday, not the ones that were already there. Memory hook Lungs better, labs worse = look below the diaphragm. NCLEX decision rule When a treated condition is improving but the WBC, temperature, or heart rate are rising, look for a new complication of the treatment instead of attributing the change to the original diagnosis. Why the other choices are wrong **Walks with a cane** is her chronic baseline; the new cue is that she now feels unsafe even with support. **Cough with scant white sputum**, **fewer crackles than on admission**, **SpO2 96 percent on room air**, and **procalcitonin down to 0.3** are tempting because they are respiratory or inflammatory data, but all show the pneumonia improving. **Lactate 1.4 mmol/L** is normal and argues against hypoperfusion at present. References 1CDC — Clinical Overview of C. diff InfectionRisk factors (antibiotic exposure, age, hospitalization) and the clinical presentation of CDI 2IDSA/SHEA 2021 Focused Update: Clostridioides difficile Infection in AdultsTesting threshold of three or more unexplained unformed stools in 24 hours and leukocytosis as a severity marker ## Clinical scenario Scenario (Stage 1 — Recognize cues) On hospital day 4 of improving pneumonia treatment, an older adult develops frequent watery stools; the respiratory picture is improving while new systemic and safety cues appear. ## Key concepts - **Clostridioides difficile infection** — Toxin-mediated colitis, most often after antibiotic exposure, presenting with three or more unformed stools in 24 hours. - **Leukocytosis trend** — A rising WBC compared with the client's own recent value is more meaningful than a single number, especially when the original infection is improving. - **Procalcitonin** — A biomarker that falls as bacterial pneumonia responds to treatment and helps separate a resolving lower respiratory infection from a new process. ## Related questions - [A nurse is caring for a client newly admitted with suspected methicillin-resistant Staphyl…](https://mymerci.kr/pages/nclex_q.php?qn_id=360517&lang=en) - [A nurse is about to enter the room of a client with Clostridioides difficile infection dur…](https://mymerci.kr/pages/nclex_q.php?qn_id=361226&lang=en) - [A 22-year-old female client presents to the emergency department with a 4-week history of …](https://mymerci.kr/pages/nclex_q.php?qn_id=361677&lang=en) - [A 65-year-old client admitted to the medical ICU with sepsis and acute delirium has just p…](https://mymerci.kr/pages/nclex_q.php?qn_id=361679&lang=en) - [A new graduate registered nurse (RN) on a medical unit just hung an intravenous antibiotic…](https://mymerci.kr/pages/nclex_q.php?qn_id=361710&lang=en) - [A nurse is caring for a client newly admitted with active Clostridioides difficile infecti…](https://mymerci.kr/pages/nclex_q.php?qn_id=363996&lang=en) - [A nurse is caring for an adult client newly admitted with suspected active pulmonary tuber…](https://mymerci.kr/pages/nclex_q.php?qn_id=366306&lang=en) - [A nurse cares for a client newly admitted with a positive surveillance culture for vancomy…](https://mymerci.kr/pages/nclex_q.php?qn_id=366709&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617300&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617300&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617300&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617300&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617300&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. 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