A nurse is assisting with the admission of a client who has a new diagnosis of Methicillin- Resistant Staphylococcus aureus (MRSA). The nurse should plan to place the client in which of the following types of transmission-based precautions?
Droplet
Contact
Protective
Airborne
The Correct Answer is B
A. Droplet: Droplet precautions are used for diseases transmitted by large droplets expelled during coughing, sneezing, or talking, such as influenza or pertussis.
B. Contact: Contact precautions are used for diseases transmitted by direct contact with the
patient or indirect contact with contaminated objects or surfaces, such as MRSA or Clostridium difficile (C. diff).
C. Protective: Protective precautions are not a standard category of transmission-based precautions. It is not applicable in this context.
D. Airborne: Airborne precautions are used for diseases transmitted by small particles suspended in the air, such as tuberculosis or measles.
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Related Questions
Correct Answer is D
Explanation
A. Pupil size and reaction: Pupil size and reaction are typically assessed to monitor neurological function and are not directly related to tissue integrity.
B. Heart rate and blood pressure: Heart rate and blood pressure are vital signs that provide information about cardiovascular function but do not specifically assess tissue integrity.
C. Respiratory rate and oxygen saturation: Respiratory rate and oxygen saturation are indicators of respiratory function and oxygenation status and are not directly related to tissue integrity.
D. Skin turgor and moisture: Skin turgor, the skin's ability to return to its normal shape after being pinched, and moisture levels are important assessments for monitoring tissue hydration and integrity. Changes in skin turgor and moisture can indicate dehydration, which can impair tissue integrity and wound healing.
Correct Answer is A
Explanation
A. Obtain a sputum culture: Obtaining a sputum culture helps identify the causative organism of pneumonia, which guides appropriate antibiotic therapy.
B. Cough and deep breathe every 6 hours: While coughing and deep breathing exercises are important for preventing complications such as atelectasis, they are not specific to pneumonia treatment and may not be appropriate for all patients with pneumonia.
C. Encourage fluid intake of 1500 mL/day: Adequate fluid intake is generally recommended for overall health but is not a specific intervention for pneumonia treatment.
D. Position the client prone: Positioning the client prone is not a standard intervention for pneumonia treatment. Depending on the severity and type of pneumonia, the client's positioning may vary, but prone positioning is not routinely recommended.
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