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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Two diarrhea stools in the last day: Diarrhea, especially if it is mild and without other severe symptoms, is not a contraindication for receiving a varicella vaccine. The child may still be able to receive the immunization if they are otherwise well. However, if the diarrhea is accompanied by fever, vomiting, or other signs of illness, the vaccine may be delayed.
B) Chemotherapy treatments: Chemotherapy treatments are a contraindication for the varicella vaccine. Chemotherapy can suppress the immune system, making the child more vulnerable to infections, including the risk of contracting varicella from the live vaccine. Immunocompromised patients should not receive live vaccines unless approved by their healthcare provider.
C) Clear rhinorrhea: Clear rhinorrhea, or a runny nose, typically indicates a mild upper respiratory condition like a cold. This is not a contraindication for receiving the varicella vaccine unless other symptoms are more severe or the child has a fever or signs of a more serious illness.
D) Medications for a cardiac anomaly: Medications for a cardiac anomaly do not generally interfere with the safety of the varicella vaccine. These medications may require careful monitoring for other reasons, but they are not contraindications to receiving the immunization, as long as the child is not immunocompromised from other causes
Correct Answer is B
Explanation
A) "A child who has leukemia and an absolute neutrophil count of 200/mm³ (2,500 to 8,000/mm³)."
This child is at significant risk for infection due to a severely low neutrophil count, indicating severe neutropenia. Discharge planning for this child would be inappropriate at this time since they need intensive monitoring and care to manage their immunocompromised status and prevent infections.
B) "A child who has a new diagnosis of type 1 diabetes mellitus and is receiving IV insulin."
This child is appropriate for discharge planning. A new diagnosis of type 1 diabetes requires thorough teaching for the family and child about blood glucose monitoring, insulin administration, dietary adjustments, and emergency management. While the child is receiving IV insulin in the hospital, once stabilized, they can be discharged with proper education and support to manage their condition at home.
C) "An adolescent who has cystic fibrosis and is receiving their yearly tune-up."
A cystic fibrosis "tune-up" refers to a period of treatment, often including IV antibiotics and respiratory therapy, to help manage the chronic condition. Since this is part of ongoing care and not an acute issue, discharge planning is not immediately appropriate until the "tune-up" is complete, and the adolescent has stabilized.
D) "An infant who has respiratory syncytial virus (RSV) and a respiratory rate of 70/min."
This infant is at risk for respiratory distress and requires close monitoring. A respiratory rate of 70/min in an infant is elevated, and the child may need additional respiratory support. Discharge planning should not be initiated until the infant's condition improves and they are stable enough to handle care at home.
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