A nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound and is about to check the patient’s pulse.
What precautions should the nurse take?
Wear sterile gloves.
Wear protective eyewear.
Wear clean gloves.
Wear an N95 respirator mask.
The Correct Answer is C
Choice A rationale
Sterile gloves are not necessary when checking a patient’s pulse. They are typically used for procedures that require aseptic technique, such as wound dressing changes or insertion of a central venous catheter.
Choice B rationale
Protective eyewear is used to protect the healthcare provider from splashes or sprays of blood, body fluids, secretions, or excretions. It is not necessary when checking a patient’s pulse.
Choice C rationale
Clean gloves should be worn when touching blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin. This includes when caring for a patient with MRSA in an abdominal wound.
Choice D rationale
An N95 respirator mask is used to protect the healthcare provider from airborne pathogens, such as tuberculosis. It is not necessary when checking a patient’s pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Granulation tissue forming at the bottom of the wound bed is a characteristic of secondary intention healing, not primary intention. In secondary intention, the wound is left open and fills with granulation tissue.
Choice B rationale
A wound that was contaminated at the time of injury would likely require secondary intention healing to allow for cleaning and observation of the wound. This is not typical of primary intention healing.
Choice C rationale
Prolonged healing of the wound is not a characteristic of primary intention healing. In primary intention, the wound edges are brought together (approximated), which allows for rapid healing.
Choice D rationale
In primary intention healing, the skin edges of the wound are sutured closed. This is the most distinctive feature of primary intention healing, as it allows for minimal scar formation and quick healing.
Correct Answer is C
Explanation
Choice A rationale
While a patient’s medication history can impact wound healing, in this case, there is no specific information provided about the patient’s medications that would suggest a delay in wound healing.
Choice B rationale
Although the patient’s cholesterol level is elevated, hyperlipidemia is not typically associated with delayed wound healing.
Choice C rationale
Prealbumin is a marker of nutritional status. A low prealbumin level, like in this patient, could indicate malnutrition, which can delay wound healing. Adequate nutrition is essential for wound healing as it provides the necessary building blocks for tissue repair.
Choice D rationale
The patient’s fasting glucose level is within the normal range, so it is unlikely to impact wound healing. While poorly controlled diabetes can delay wound healing, this patient’s diabetes appears to be well-controlled.
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