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: Collecting data to identify barriers to learning is the first action that the nurse should take. This is based on the principle of assessment, which states that the nurse should gather information about the needs, interests, and characteristics of the target population before planning any intervention. The nurse should assess the barriers that may prevent the adolescents from participating in or benefiting from the program, such as lack of knowledge, motivation, access, or support.
Choice B reason: Establishing methods to evaluate program outcomes is not the first action that the nurse should take. This is based on the principle of evaluation, which states that the nurse should measure the effectiveness and impact of the intervention after implementing it. The nurse should determine the criteria and indicators that will be used to evaluate the program outcomes, such as changes in knowledge, attitudes, behaviors, or health status.
Choice C reason: Obtaining visual aids that feature adolescents is not the first action that the nurse should take. This is based on the principle of implementation, which states that the nurse should deliver the intervention using appropriate strategies and resources. The nurse should obtain visual aids that are relevant, accurate, and appealing to the adolescents, and that can enhance the learning process and the message delivery.
Choice D reason: Providing computer-based education is not the first action that the nurse should take. This is based on the principle of implementation, which states that the nurse should deliver the intervention using appropriate strategies and resources. The nurse should provide computer-based education if it is feasible, accessible, and preferred by the adolescents, and if it can facilitate the learning objectives and outcomes.
Correct Answer is B
Explanation
Choice A reason: The test does not monitor the progression of the disease, as it only detects the presence of antibodies to HIV, not the amount of virus or the damage to the immune system. Other tests, such as viral load and CD4 count, are used to monitor the progression of HIV infection and the response to treatment.
Choice B reason: The test measures antibodies to the virus, which are produced by the immune system in response to HIV infection. The test is used to screen for HIV infection and to confirm the diagnosis. A positive result indicates that the person has been exposed to HIV and has developed antibodies to the virus.
Choice C reason: The test results are not accurate 24 hours after exposure to the virus, as it takes time for the body to produce enough antibodies to be detected by the test. The window period, which is the time between exposure to HIV and a positive test result, varies from person to person, but it can range from 3 weeks to 3 months. Therefore, a negative result does not necessarily rule out HIV infection, and a repeat test may be needed after the window period.
Choice D reason: A positive result does not require initiating immunoglobulin administration, as immunoglobulin is not a treatment for HIV infection. Immunoglobulin is a preparation of antibodies that can provide temporary protection against some infections, but it does not affect HIV. A positive result requires further confirmation by a more specific test, such as the Western blot, and referral to a specialist for treatment and counseling.
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