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 B

Explanation

The correct answer is choiceb. Place the client in Trendelenburg position.

Choice A rationale:

Loosely wrapping the cord with petroleum gauze is not recommended.Instead, the cord should be wrapped with sterile saline-soaked gauze to prevent it from drying out and to minimize infection risk.

Choice B rationale:

Placing the client in Trendelenburg position helps to relieve pressure on the prolapsed cord by using gravity to shift the fetus away from the pelvis. This position helps to improve blood flow through the umbilical cord until delivery can be arranged.

Choice C rationale:

Evaluating uterine tone is not directly related to managing a prolapsed umbilical cord.The priority is to relieve pressure on the cord to prevent fetal hypoxia.

Choice D rationale:

Applying fundal pressure is contraindicated as it can increase pressure on the prolapsed cord, worsening the situation.

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

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