A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following items should the nurse wear?
Clean gloves
Protective eyewear
Sterile gloves
Surgical mask
The Correct Answer is A
Choice A reason: Clean gloves are necessary when touching or being in close proximity to any wound, especially one that is infected with MRSA. MRSA is a highly contagious bacterium that can spread through direct contact with the infected area or through indirect contact with contaminated objects. Wearing clean gloves helps prevent the transmission of MRSA to the nurse and to other patients.
Choice B reason: Protective eyewear is not typically required for checking a patient's pulse. However, if there is a risk of splashing or spraying of bodily fluids, protective eyewear becomes necessary to protect the mucous membranes of the eyes from exposure to infectious materials.
Choice C reason: Sterile gloves are used during procedures that require an aseptic technique, such as the changing of a sterile dressing or during invasive procedures. Checking a patient's pulse does not require sterile gloves, as it is not an aseptic procedure.
Choice D reason: A surgical mask should be worn if there is a risk of droplet transmission or if the nurse will be in close contact with the patient's wound. MRSA can be present in nasal secretions and can be spread by droplets, so wearing a mask can provide an additional layer of protection against the transmission of MRSA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: While providing a newborn's first bath, there is minimal risk of exposure to infectious fluids that would necessitate eye protection. However, standard precautions should always be followed.
Choice B reason: When giving personal care to an infant who is HIV-positive, standard precautions should be followed, which includes wearing gloves. Eye protection is not typically required unless there is a risk of splashing bodily fluids.
Choice C reason: Suctioning secretions from a child's newly placed tracheostomy tube requires eye protection because there is a high risk of secretions being expelled forcefully, which could contact the mucous membranes of the eyes.
Choice D reason: Withdrawing cord blood from a neonate generally does not require eye protection unless there is a risk of blood splatter. Standard precautions, including the use of gloves, should be sufficient.
Choice E reason: Transporting a cerebrospinal fluid specimen to the laboratory does not require the nurse to wear eye protection. However, the nurse should ensure that the specimen is sealed properly to prevent any leaks.
Correct Answer is A
Explanation
Choice A reason: When a patient has an elevated temperature, the body is attempting to cool down through vasodilation, which is why the skin may appear flushed and feel warm. Removing excess blankets can help facilitate the body's natural cooling process. Offering fluids is also crucial as fever can lead to dehydration, especially if there is sweating. Adequate hydration helps regulate body temperature and replaces fluids lost through sweating. The normal body temperature range is typically between 36.5°C to 37.5°C (97.7°F to 99.5°F). When the body temperature rises above this range, interventions such as removing blankets and providing fluids can be effective in reducing fever.
Choice B reason: Increasing the patient's activity is not advisable when they have an elevated temperature and are experiencing severe fatigue. Activity generates heat and can raise body temperature further, exacerbating the fever. Rest is recommended to conserve energy and reduce metabolic demand, which can help lower the body temperature.
Choice C reason: The use of ice bags can be a rapid cooling measure but must be used with caution. Direct application of ice to the skin can cause vasoconstriction and shivering, which can actually increase the body's core temperature. It is generally reserved for hyperthermia or heatstroke when immediate cooling is necessary. For a simple fever, less aggressive cooling measures are usually preferred.
Choice D reason: Decreasing the patient's intake is not appropriate unless there is a specific contraindication, such as vomiting or risk of aspiration. Adequate nutrition supports the immune system and provides the energy needed for the body to combat the underlying cause of the fever.
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