A home health nurse manager is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?
Remove fresh flowers from the client's home.
Wear a mask when within 3 feet of the client.
Encourage the client to use a HEPA filter in the house.
Double bag soiled dressings in polyethylene bags.
The Correct Answer is D
Choice A reason: Removing fresh flowers from the client's home is not an action that the nurse should take when caring for a client who has MRSA. Fresh flowers do not pose a risk of transmitting MRSA, and may provide some psychological benefits for the client.
Choice B reason: Wearing a mask when within 3 feet of the client is not an action that the nurse should take when caring for a client who has MRSA. MRSA is not an airborne infection, and a mask is not necessary to prevent its spread. The nurse should wear gloves and a gown when in contact with the client or the client's environment, and perform hand hygiene before and after the contact.
Choice C reason: Encouraging the client to use a HEPA filter in the house is not an action that the nurse should take when caring for a client who has MRSA. A HEPA filter is not effective in removing MRSA from the air, and may not have any impact on the client's health. The nurse should educate the client on how to clean and disinfect the surfaces and items that may be contaminated with MRSA, such as bedding, towels, and personal items.
Choice D reason: Double bagging soiled dressings in polyethylene bags is an action that the nurse should take when caring for a client who has MRSA. This is a standard precaution to prevent the exposure of other people or the environment to the infectious material. The nurse should also label the bags as biohazardous waste and dispose of them according to the agency's policy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Determining the client's understanding of her living situation is the first action that the nurse should take. This is based on the principle of client-centered care, which states that the nurse should respect the client's values, preferences, and needs, and involve the client in the decision-making process. The nurse should assess the client's perception of her homelessness, the factors that contributed to it, and the resources that are available to her.
Choice B reason: Assisting the client to develop goals for obtaining shelter is not the first action that the nurse should take. This is an important intervention, but it should be done after the nurse has assessed the client's understanding of her living situation and explored the client's readiness and motivation to change.
Choice C reason: Discussing the risks of being homeless with the client is not the first action that the nurse should take. This is an important intervention, but it should be done after the nurse has assessed the client's understanding of her living situation and established a trusting relationship with the client. The nurse should avoid being judgmental or paternalistic, and instead use a harm reduction approach that focuses on minimizing the negative consequences of homelessness.
Choice D reason: Developing client teaching using a variety of strategies is not the first action that the nurse should take. This is an important intervention, but it should be done after the nurse has assessed the client's understanding of her living situation and identified the client's learning needs and preferences. The nurse should use strategies that are appropriate for the client's literacy level, language, culture, and cognitive ability.
Correct Answer is A
Explanation
Choice A reason: Motor vehicle safety is the topic that the nurse should give priority to, as it is the leading cause of death for adolescents. According to the World Health Organization (WHO), road traffic injuries are the top cause of death among 15- to 19-year-olds globally, accounting for 115 000 deaths in 2019¹. Adolescents are vulnerable road users, especially as drivers, passengers, pedestrians, cyclists, or motorcyclists. The nurse should educate the adolescents about the risk factors and prevention strategies for road traffic injuries, such as wearing seat belts, helmets, and reflective clothing, avoiding distractions, alcohol, and drugs, and following traffic rules and signs.
Choice B reason: Sports injury prevention is not the topic that the nurse should give priority to, as it is not the leading cause of death for adolescents. Sports injuries are common among adolescents, as they are physically active and participate in various sports and recreational activities. Sports injuries can cause pain, disability, or death, depending on the type, severity, and location of the injury. The nurse should educate the adolescents about the risk factors and prevention strategies for sports injuries, such as warming up, cooling down, stretching, using protective equipment, and seeking medical attention when needed.
Choice C reason: Substance abuse prevention is not the topic that the nurse should give priority to, as it is not the leading cause of death for adolescents. Substance abuse is the harmful use of psychoactive substances, such as alcohol, tobacco, or drugs, that can affect the health and well-being of adolescents. Substance abuse can cause acute or chronic effects, such as intoxication, overdose, addiction, organ damage, or mental disorders. The nurse should educate the adolescents about the risk factors and prevention strategies for substance abuse, such as avoiding peer pressure, coping with stress, seeking help, and accessing treatment.
Choice D reason: Gun safety is not the topic that the nurse should give priority to, as it is not the leading cause of death for adolescents. Gun safety is the practice of using firearms in a safe and responsible manner, to prevent accidental or intentional injuries or deaths. Gun safety can involve proper handling, storage, and disposal of firearms, as well as education and awareness about the dangers and consequences of gun violence. The nurse should educate the adolescents about the risk factors and prevention strategies for gun safety, such as avoiding access to firearms, reporting threats, and supporting non-violent solutions.
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