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 A
Explanation
Choice A reason: This response demonstrates empathy and active listening. It acknowledges the client's feelings without judgment and opens the door for further discussion about their concerns. It is a therapeutic communication technique that helps build rapport and trust between the nurse and the client. When a client feels understood, it can reduce their anxiety and promote a sense of safety, which may improve their ability to sleep and concentrate.
Choice B reason: While it is important for clients to communicate with their healthcare providers, this response might make the client feel dismissed or that their immediate concerns are not being addressed by the nurse. It could be perceived as deflecting the responsibility to someone else, rather than the nurse providing support at that moment.
Choice C reason: Asking the client to self-reflect on the reasons for their anxiety could be helpful, but it might also be overwhelming for them if they are already in a heightened state of anxiety. This question should be asked with caution and at an appropriate time when the client is more likely to engage in productive self-reflection.
Choice D reason: This statement minimizes the client's experience by suggesting that their problem is common and insignificant. It fails to acknowledge the severity of the client's distress and does not offer any comfort or assistance. It is not a therapeutic response because it does not validate the client's feelings or encourage further communication.
Correct Answer is B
Explanation
Choice A reason: Droplet precautions are used for diseases that are spread by large respiratory droplets produced by coughing, sneezing, or talking. Examples include influenza, pertussis, and mumps. However, tuberculosis is not spread through large droplets but through airborne particles that can remain suspended in the air for long periods.
Choice B reason: Airborne precautions are necessary for diseases that are transmitted by smaller droplets, which can be suspended in the air for extended periods and can be inhaled. Tuberculosis, particularly pulmonary or laryngeal tuberculosis with a productive cough, requires airborne precautions because the bacteria can be expelled into the air and inhaled by others. The nurse should initiate airborne precautions, which include placing the patient in a negative pressure room and using personal protective equipment such as N95 respirators.
Choice C reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. Examples include infections caused by multidrug-resistant organisms, scabies, and norovirus. Tuberculosis is not spread by direct contact, so contact precautions are not the primary method of prevention.
Choice D reason: Protective isolation, also known as neutropenic or reverse isolation, is used to protect immunocompromised patients from infections. It is not used for patients with tuberculosis, as the goal is to protect others from the tuberculosis bacteria, not to protect the patient from external infections.
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