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 D
Explanation
Choice A rationale:
Incorrect. Deep-breathing exercises could potentially worsen stridor. Stridor is a high-pitched, wheezing sound caused by a partial obstruction of the upper airway. Deep breathing can increase airflow through the narrowed airway, making the stridor more pronounced and potentially worsening the obstruction. In severe cases, it could lead to complete airway obstruction and respiratory distress.
Risk of aggravation: Deep-breathing exercises could aggravate the underlying cause of stridor, such as laryngeal edema or vocal cord dysfunction, by increasing inflammation or muscle tension in the airway.
Delay in definitive treatment: Focusing on deep-breathing exercises might delay more definitive interventions, such as intubation, which might be necessary to secure the airway and prevent respiratory failure.
Choice B rationale:
Incorrect. While albuterol nebulizer therapy can be helpful for bronchospasm, it is not the first-line treatment for stridor. Stridor is typically caused by an upper airway obstruction, and albuterol primarily targets the lower airways (bronchioles).
Limited effectiveness: Albuterol might not be effective in reducing stridor caused by upper airway obstruction, as it does not directly address the narrowing of the airway.
Potential for adverse effects: Albuterol can cause tachycardia, tremors, and anxiety, which could further complicate the patient's condition.
Choice C rationale:
Not the most immediate action. While calling a Rapid Response might be necessary if the patient's condition deteriorates, the first priority is to secure the airway and ensure adequate ventilation.
Time-consuming: Activating a Rapid Response team can take several minutes, and the patient's condition might not allow for that delay.
Choice D rationale:
Prioritizes airway management: Intubation is the most effective way to secure the airway and ensure adequate ventilation in a patient with stridor. It bypasses the obstruction and allows for controlled delivery of oxygen and ventilation.
Addresses potential for deterioration: Stridor can rapidly progress to complete airway obstruction, so prompt preparation for intubation is crucial to prevent respiratory failure.
Involves the primary healthcare provider: Consulting the primary health care provider ensures timely decision-making, appropriate medication administration (such as sedatives or paralytics for intubation), and coordination of care.
Correct Answer is B
Explanation
Choice A rationale:
While advancing age is a significant risk factor for cancer, it is not considered the single biggest risk factor. The risk of developing cancer does increase with age, primarily due to the accumulation of DNA damage over time. This damage can arise from various sources, including exposure to carcinogens, errors in DNA replication, and oxidative stress. With age, the body's ability to repair DNA damage also declines, making cells more susceptible to cancerous changes.
However, it's important to note that cancer can develop at any age, and even younger individuals can be affected if exposed to other significant risk factors.
Choice B rationale:
Exposure to tobacco is widely recognized as the single biggest risk factor for developing cancer. It is estimated to be responsible for about 25-30% of all cancer deaths worldwide.
Tobacco smoke contains over 70 known carcinogens, which are substances that can damage DNA and lead to cancer. These carcinogens can affect various organs in the body, including the lungs, mouth, throat, esophagus, stomach, pancreas, liver, bladder, kidney, cervix, and colon.
The risk of cancer increases with the amount and duration of tobacco use. Even exposure to secondhand smoke can increase the risk of cancer.
Quitting tobacco use is the most effective way to reduce the risk of cancer.
Choice C rationale:
Exposure to occupational chemicals is a known risk factor for certain types of cancer, such as lung cancer, bladder cancer, and leukemia. However, it is not considered the single biggest risk factor for developing cancer overall.
The risk of cancer from occupational chemicals depends on the specific chemical, the level of exposure, and the duration of exposure.
Workplace safety measures, such as using protective equipment and limiting exposure to hazardous chemicals, can help reduce the risk of cancer.
Choice D rationale:
Infection with certain viruses, known as oncoviruses, can increase the risk of developing certain types of cancer. For example, infection with human papillomavirus (HPV) can increase the risk of cervical cancer, and infection with hepatitis B virus (HBV) can increase the risk of liver cancer.
However, oncoviruses are not considered the single biggest risk factor for developing cancer overall. Vaccines are available to protect against some oncoviruses, such as HPV and HBV.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.