A nurse is teaching a newly licensed nurse about the care of a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following statements by the newly licensed nurse Indicates an understanding of the teaching?
"I will remove my gown before my gloves after providing client care."
"I will place the client in a private room."
"I will tell the client's visitors to wear a mask when they are within 3 feet of the client."
"I will wear an N95 respirator mask when caring for the client."
"I will wear an N95 respirator mask when caring for the client."
The Correct Answer is B
MRSA is a highly contagious infection that can spread through direct contact or through contaminated surfaces. Placing the client in a private room helps minimize the risk of spreading
the infection to other patients or healthcare providers. This measure is known as "contact precautions" and is a standard practice for managing MRSA infections.
When removing personal protective equipment (PPE) after caring for a client with MRSA, it is important to remove the gloves first, followed by the gown. This sequence helps prevent contamination of the hands.
While it is generally important for visitors to practice good hand hygiene, wearing a mask when they are within 3 feet of the client may not be necessary unless they are providing direct care and are in close proximity to the client's respiratory secretions.
The use of N95 respirator masks is primarily indicated for airborne precautions, such as in cases of tuberculosis. For MRSA, the primary mode of transmission is through direct contact or contaminated surfaces, so standard precautions and appropriate hand hygiene are the key preventive measures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse's priority finding in this case would be a change in appearance of a mole on the shoulder. Changes in the appearance of moles can be an indication of skin cancer or melanoma, which is a serious and potentially life-threatening condition. It is important for the nurse to assess the mole further and report any concerning changes to the healthcare provider for appropriate evaluation and management. The other findings, such as skin tags, a flat discolored area of skin, or atrophic fingers, may require further assessment and interventions, but they are not as immediately concerning as a potential change in a mole that could indicate skin cancer.
Correct Answer is C
Explanation
A. Change the tubing set every 72 hr:
Enteral feeding sets should generally be changed every 24 hours to reduce the risk of bacterial contamination.
B. Heat the formula to 40.5° C (105° F):
Enteral formula should be administered at room temperature. Heating it can alter the composition and pose a burn risk to the gastrointestinal mucosa.
C. Aspirate residual volume every 4 hr:
This is recommended to assess tolerance to the feeding and prevent complications like aspiration. Holding feedings may be considered based on facility policy if residuals are high.
D. Flush the tubing with 10 mL of water every 2 hr:
While flushing is necessary to maintain patency, the typical flush is 30 mL every 4 hr (or before and after medications/feedings), unless otherwise specified.
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