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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

While observing the patient’s respiratory status is important in all patient care, it is not the priority action in this case. The patient’s decreased level of consciousness and inability to swallow increase the risk of aspiration, which can lead to respiratory complications.

Choice B rationale

Elevating the head of the patient’s bed 30° to 45° is the priority action. A patient who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying down also increases this risk. The priority action by the nurse is to keep the head of the bed elevated to promote gastric emptying and reduce the risk of aspiration.

Choice C rationale

Monitoring intake and output every 8 hours is important for assessing the patient’s hydration status and nutritional needs. However, it is not the priority action in this case. The risk of aspiration due to the patient’s decreased level of consciousness and inability to swallow takes precedence.

Choice D rationale

Checking residual volume every 4 to 6 hours is a standard practice when administering continuous enteral feedings through a gastrostomy tube. It helps to ensure that the patient is tolerating the feedings and not at risk for aspiration due to high gastric residuals. However, in this case, the priority is to prevent aspiration by elevating the head of the bed.

A. Use soap to clean the patient’s skin. B. Apply a barrier cream to the patient’s skin. C. Avoid applying friction when drying the patient’s skin. D. Use warm water to clean the patient’s skin.

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale

Using soap to clean the patient’s skin is not the best practice. Soap can dry out and irritate the skin, especially in patients with urinary incontinence. It can disrupt the skin’s natural pH balance and make it more susceptible to damage.

Choice B rationale

Applying a barrier cream to the patient’s skin is a recommended practice. Barrier creams provide a protective layer on the skin that can help prevent irritation from urine. They can also help to keep the skin moisturized, which is important for maintaining skin integrity.

Choice C rationale

Avoiding friction when drying the patient’s skin is crucial. Friction can cause further damage to the skin, especially in areas that are already irritated or broken down due to incontinence. It’s recommended to gently pat the skin dry rather than rubbing it.

Choice D rationale

Using warm water to clean the patient’s skin is a good practice. Warm water is less irritating to the skin than hot water and can help to cleanse the area without causing additional discomfort or damage.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a care plan for a patient with a decreased level of consciousness who is receiving continuous enteral feedings through a gastrostomy tube due to an inability to swallow.What should be the nurse’s priority action?

Correct Answer is B

Explanation

A nurse is providing skin care for a patient with urinary incontinence. What actions should the nurse take?

Correct Answer is ["B","C","D"]

Explanation

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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?