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 D
Explanation
Choice A reason: The severity of the condition may not always correlate with the level of pain experienced by the client. Pain is a subjective experience, and two individuals with the same condition may report different levels of pain.
Choice B reason: Vital signs can be indicators of pain but are not always reliable. For example, some clients may exhibit increased heart rate or blood pressure when in pain, while others may not show significant changes in vital signs despite severe pain.
Choice C reason: Nonverbal behavior can be an indicator of pain, especially in clients who are unable to communicate verbally. However, it is still considered less reliable than self-report because it is subject to interpretation by the observer.
Choice D reason: Self-report of pain is considered the most reliable indicator of a patient's pain experience. It is a direct expression of the client's experience and should be the primary source of assessment whenever possible.
Correct Answer is D
Explanation
Choice A reason: The FACES pain scale is commonly used for children who are able to select a face that best describes their pain. However, this scale is not suitable for a 6-month-old infant post-myringotomy, as infants of this age cannot verbally communicate or reliably choose a face to represent their pain level.
Choice B reason: The Visual Analog Scale (VAS) is typically used for older children and adults who can understand and indicate their level of pain by marking a point on a line. This scale is not appropriate for infants due to their developmental stage and inability to communicate or understand the concept of the scale.
Choice C reason: The Oucher pain scale includes both a photographic scale with pictures of children's faces showing different levels of pain and a numerical scale. While it is designed for children aged 3 to 12 years, it is not suitable for infants, as they cannot verbally express their pain or point to a photograph to indicate their pain level.
Choice D reason: The FLACC scale, which stands for Face, Legs, Activity, Cry, and Consolability, is an appropriate choice for assessing pain in infants and young children who are non-verbal. It involves observing specific behaviors and assigning a score from 0 to 2 for each category, resulting in a total score between 0 and 10. This observational tool allows healthcare providers to assess pain levels based on the infant's behavior and physiological responses.
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