A nurse is admitting a client who has a wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which of the following types of precautions should the nurse plan to initiate?
Protective.
Droplet.
Airborne.
Contact.
The Correct Answer is D
Choice A rationale:
Protective precautions (also known as reverse isolation) are implemented to protect clients with compromised immune systems from potential pathogens brought in by healthcare providers or visitors. This choice would be appropriate for clients who are highly susceptible to infections, but it's not the primary choice for managing a wound infected with MRSA.
Choice B rationale:
Droplet precautions are utilized for diseases spread by respiratory droplets. MRSA is primarily spread through direct contact with contaminated skin or objects. Therefore, droplet precautions are not the most appropriate choice for this scenario.
Choice C rationale:
Airborne precautions are designed for diseases that spread via small particles suspended in the air, such as tuberculosis. MRSA does not spread through the airborne route, so airborne precautions are not necessary for a wound infection with MRSA.
Choice D rationale:
Contact precautions are the correct choice when dealing with MRSA infections. MRSA is primarily transmitted through direct physical contact or contact with contaminated objects. By implementing contact precautions, the nurse can effectively prevent the spread of the infection to other clients and healthcare workers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Admission assessment of a new client requires comprehensive evaluation, critical thinking, and clinical judgment. This task is within the scope of a registered nurse's responsibilities and should not be delegated to an LPN.
Choice B rationale:
Evaluating changes to a client's pressure ulcer also involves clinical judgment and assessment skills that fall within the domain of a registered nurse's role.
Choice C rationale:
This is the correct choice. Tracheostomy care involves routine and standardized procedures that an LPN can perform under the supervision of a registered nurse. LPNs are trained to provide this type of care safely and effectively.
Choice D rationale:
Administering a blood transfusion is a complex procedure that requires careful monitoring and assessment for potential adverse reactions. This task is typically within the scope of a registered nurse's practice, not an LPN's.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale:
This choice is not correct because verifying the oxygen flow rate every other day is not part of the discharge teaching for a client on home oxygen therapy. The flow rate should be checked regularly, not just every other day, to ensure the client's safety and well-being.
Choice B rationale:
This choice is correct. Checking the tops of the ears for skin breakdown is important in a client using a nasal cannula for oxygen therapy. Prolonged use of the cannula can lead to irritation and pressure-related skin breakdown behind the ears.
Choice C rationale:
This choice is correct. Posting "no smoking signs in a prominent location in the home" is an important safety measure for a client on oxygen therapy. Oxygen supports combustion, and smoking in the presence of oxygen can lead to fire hazards.
Choice D rationale:
This choice is correct. Checking the cannula position on a regular basis is essential to ensure that the oxygen is being delivered effectively and that the client is not experiencing discomfort or skin breakdown due to improper positioning.
Choice E rationale:
This choice is correct. Applying petroleum ointment to the nares if they become dry and irritated is a suitable intervention to maintain the client's comfort and prevent skin irritation from the cannula.
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