A nurse is providing care for a patient who has a methicillin-resistant Staphylococcus aureus (MRSA) infection, which was cultured from the urine. What is the most appropriate action for the nurse to take?
Utilize a respirator when handling urine output.
Restrict visitors strictly to immediate family members only.
Wash hands only after removing gloves post-care.
Prepare to administer vancomycin.
The Correct Answer is D
Choice A rationale:
Utilizing a respirator when handling urine output is not the most appropriate action for a nurse caring for a patient with MRSA.
MRSA is not typically transmitted through the air, but rather through direct contact with infected wounds or contaminated surfaces.
While a respirator may offer some protection against airborne particles, it is not necessary for routine care of a patient with MRSA.
It is more important to focus on hand hygiene and other infection control measures.
Choice B rationale:
Restricting visitors strictly to immediate family members only is not necessary for a patient with MRSA.
While it is important to limit the number of visitors to reduce the risk of spreading infection, there is no need to restrict visitors to immediate family members only.
Visitors should be instructed on proper hand hygiene and other infection control measures, and they should avoid contact with the patient's wounds or dressings.
Choice C rationale:
Washing hands only after removing gloves post-care is not sufficient for preventing the spread of MRSA. It is important to wash hands before and after any contact with the patient, even when wearing gloves.
This is because gloves can become contaminated with bacteria, and hand washing helps to remove any bacteria that may have gotten on the hands.
Choice D rationale:
Preparing to administer vancomycin is the most appropriate action for a nurse caring for a patient with MRSA. Vancomycin is an antibiotic that is effective against MRSA.
It is often used to treat MRSA infections, and it can help to prevent the infection from spreading.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Prednisone is a corticosteroid that suppresses the body's natural production of cortisol. Cortisol is a hormone that is essential for life, and it plays a role in many important bodily functions, including:
Regulating blood sugar levels Maintaining blood pressure Reducing inflammation Responding to stress
When a person takes prednisone for a long period of time, their body begins to rely on the medication to provide cortisol. If the medication is stopped suddenly, the body cannot produce enough cortisol on its own, which can lead to a life-threatening condition called adrenal insufficiency.
Adrenal insufficiency can cause a variety of symptoms, including: Extreme fatigue
Weakness Dizziness Nausea Vomiting Abdominal pain Confusion
Loss of consciousness
To prevent adrenal insufficiency, it is important to taper off prednisone slowly over a period of time. This allows the body to gradually adjust to producing cortisol on its own.
Here are some additional details about why prednisone should never be discontinued abruptly: The risk of adrenal insufficiency is highest when prednisone has been taken for more than 3 weeks. The longer a person has been taking prednisone, the slower the taper should be.
It is important to follow the tapering instructions provided by the healthcare provider.
If a person experiences any symptoms of adrenal insufficiency, they should seek medical attention immediately.
Correct Answer is D
Explanation
Rationale for Choice A:
While it's important for the primary healthcare provider to be informed about the CD4+ results, it's not the first action the nurse should take. The priority is to implement appropriate infection control measures to protect the patient, other patients, and healthcare staff.
CD4+ cell count is a crucial indicator of the patient's immune status. A count of 180/mm is significantly low, suggesting a weakened immune system and increased vulnerability to infections. However, informing the provider alone doesn't directly address the immediate need for infection control.
Rationale for Choice B:
Airborne Precautions are specifically used for patients with known or suspected airborne infections, such as tuberculosis, measles, or varicella. These precautions involve the use of negative pressure rooms and N95 respirators.
In this case, the patient's TB skin test was negative, indicating no evidence of active tuberculosis infection. Implementing Airborne Precautions unnecessarily could lead to excessive resource utilization and potential stigmatization of the patient.
Rationale for Choice C:
Droplet Precautions are used for patients with infections that can be spread through large respiratory droplets, such as influenza, pertussis, or meningococcal meningitis. These precautions involve the use of masks and eye protection.
While the patient's symptoms of fever, night sweats, and severe cough could be consistent with a droplet-spread infection, there's no definitive evidence to support this at the present time. Initiating Droplet Precautions without a clear indication could also lead to unnecessary resource use and potential anxiety for the patient.
Rationale for Choice D:
Standard Precautions are the foundation of infection control and should be used for all patients, regardless of their known or suspected infection status. These precautions include hand hygiene, use of personal protective equipment (PPE) when indicated, and safe handling of sharps and bodily fluids.
By implementing Standard Precautions, the nurse can effectively minimize the risk of transmission of pathogens, protecting both the patient and other individuals in the healthcare setting. This is the most appropriate first action to ensure a safe and appropriate level of care.
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