A nurse in a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

Remove personal protective equipment after leaving the client’s room.

Ensure that the negative air pressure is active for the client's room.

Restrict the client's visitors

Wear a gown when assisting the client with personal hygiene.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Wear a gown when assisting the client with personal hygiene. Choice A rationale: Removing personal protective equipment (PPE) after leaving the client’s room is incorrect. PPE should be removed before leaving the room to prevent the spread of MRSA to other areas. Choice B rationale: Ensuring that the negative air pressure is active for the client’s room is incorrect. Negative air pressure rooms are typically used for airborne infections, such as tuberculosis, not for MRSA, which is spread by contact. Choice C rationale: Restricting the client’s visitors is not necessary. Visitors should follow contact precautions, such as wearing gowns and gloves, but they do not need to be restricted. Choice D rationale: Wearing a gown when assisting the client with personal hygiene is correct. This helps prevent the spread of MRSA by protecting the nurse’s clothing and skin from contamination.

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Correct Answer is C

Explanation

The correct answer is C. "Close your mouth around the mouthpiece." The rationale for this instruction is that it ensures that the medication reaches the lungs and does not escape through the mouth or nose. Albuterol is a bronchodilator that relaxes muscles in the airways and increases airflow to the lungs. It is used to treat or prevent bronchospasm, or narrowing of the airways, in people with asthma or certain types of chronic obstructive pulmonary disease (COPD). It is also used to prevent exercise-induced bronchospasm. Albuterol is delivered through a metered dose inhaler (MDI), which is a device that releases a measured amount of medication with each puff. To use an albuterol MDI correctly, the client should follow these steps :

Shake the inhaler well before each spray.
Remove the cap and look at the mouthpiece to make sure it is clean.
Breathe out fully.
Put the mouthpiece between your lips and close your mouth around it.
Press down on the inhaler to release the medication as you start to breathe in slowly.
Breathe in slowly and deeply over 3 to 5 seconds.
Hold your breath for 10 seconds to allow the medication to reach your airways.
Breathe out slowly.
If you need another puff, wait 1 minute and repeat steps 4 to 8.

A. Irrigation of a wound with antibiotic solution B. Placement of a central venous catheter C. Insertion of a nasogastric tube D. Administration of an iron injection using the Z-track technique

Correct Answer is B

Explanation

The correct answer is B. Placement of a central venous catheter.

Rationale: The nurse should identify that informed consent is required for the placement of a central venous catheter, as this is an invasive procedure that carries significant risks and benefits that need to be explained to the client before obtaining consent. Informed consent is not required for irrigation of a wound with antibiotic solution, as this is a routine nursing intervention that does not involve significant risks or benefits.

Informed consent is not required for the insertion of a nasogastric tube, as this is a common nursing procedure that does not involve significant risks or benefits. Informed consent is not required for the administration of an iron injection using the Z-track technique, as this is a standard medication administration technique that does not involve significant risks or benefits.

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A nurse in a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is about to start using an albuterol metered- dose inhaler. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

Correct Answer is B

Explanation

A nurse on a medical-surgical unit is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?

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A nurse is providing teaching to a client who is undergoing radiation therapy and has stomatitis. Which of the following responses by the client indicates an understanding of the teaching?

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A nurse is talking with a client who refuses a blood transfusion for religious reasons. Which of the following responses should the nurse make?