A nurse is 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?

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

Place the client in a room with a high-efficiency particulate air (HEPA) filter.

How the client wear a mask when they are out of their

Don gloves prior to assisting the client with brushing their teeth.

Answer and Explanation

The Correct Answer is D

A) "Ensure that the negative air pressure is active for the client’s room.": Negative air pressure is used for airborne precautions, such as in the case of tuberculosis or other airborne infections. MRSA is primarily spread through direct contact, not airborne transmission, so negative air pressure is not necessary in this situation.

B) "Place the client in a room with a high-efficiency particulate air (HEPA) filter.": A HEPA filter is used for airborne precautions to filter out airborne particles like those found in diseases such as tuberculosis or measles. Since MRSA is transmitted through direct contact and not airborne particles, placing the client in a room with a HEPA filter is not necessary.

C) "Have the client wear a mask when they are out of their room.": MRSA is typically spread by direct contact with infected wounds, bodily fluids, or contaminated surfaces. It is not transmitted via respiratory droplets, so there is no need for the client to wear a mask when they leave their room. The focus should be on contact precautions rather than respiratory precautions.

D) "Don gloves prior to assisting the client with brushing their teeth.": MRSA is a contact-borne infection, so it is essential to use proper personal protective equipment, such as gloves, when coming into direct contact with the client or any of their bodily fluids or contaminated items (such as toothbrushes). Donning gloves prior to assisting with brushing their teeth ensures that the nurse avoids direct contact with potential sources of infection. This is an important measure in preventing the spread of MRSA.

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Correct Answer is C

Explanation

A) Decreased hemoglobin level: A decreased hemoglobin level is not an expected or desirable outcome of taking furosemide. While furosemide can cause fluid loss, it does not directly affect red blood cell production or hemoglobin levels. A decrease in hemoglobin could indicate anemia or another underlying issue, which should be addressed separately.

B) Increased weight of 0.91 kg (2 lb): An increase in weight, especially in a client with heart failure, could indicate fluid retention rather than effective diuresis. Furosemide is a diuretic that helps reduce fluid buildup, so an increase in weight would typically suggest that the medication is not effectively managing fluid overload, which is a key issue in heart failure.

C) Increased urinary output: An increase in urinary output is a clear indicator that furosemide is working effectively. Furosemide is a loop diuretic, which promotes the excretion of sodium and water, leading to increased urine output. This helps reduce fluid volume in the body, which is beneficial for a client with heart failure.

D) Decreased BUN level: While furosemide can affect kidney function, a decrease in blood urea nitrogen (BUN) level is not a direct indicator of the medication’s effectiveness. BUN can be influenced by various factors such as hydration status, kidney function, and protein intake. A decreased BUN level does not directly correlate with furosemide's effectiveness in treating heart failure.

A. "My baby will receive the rotavirus immunization orally." B. should expect my baby to have a high fever for 24 hours after an immunization." C. "I should not feed my baby anything for hours prior to an immunization." D. "My baby will receive three doses of the meningococcal immunization before kindergarten."

Correct Answer is A

Explanation

A) "My baby will receive the rotavirus immunization orally.":
This statement is correct. The rotavirus vaccine is given orally in two or three doses depending on the specific vaccine used (Rotarix or RotaTeq). The vaccine is administered in the mouth and helps protect against rotavirus infections, which can cause severe diarrhea in infants and young children.

B) "I should expect my baby to have a high fever for 24 hours after an immunization.":
This statement is incorrect. While it is common for infants to experience mild side effects after immunizations, such as a low-grade fever or irritability, a high fever is not typically expected. If the baby develops a high fever (above 100.4°F), the guardian should seek advice from the healthcare provider, as it could indicate a reaction or infection.

C) "I should not feed my baby anything for hours prior to an immunization.":
This statement is incorrect. There is no need to withhold feeding before an immunization, and the baby should be fed as usual. In fact, feeding the infant before the appointment may help comfort them and reduce stress during the visit.

D) "My baby will receive three doses of the meningococcal immunization before kindergarten.":
This statement is incorrect. The meningococcal vaccine is typically administered starting at age 11, with a second dose given at age 16. For infants and young children, the vaccine is not part of the routine immunization schedule. Meningococcal vaccination before kindergarten is not recommended for infants at 2 months of age.

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A nurse is 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

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Explanation

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