Which infection control measure, by the nurse, reduces the potential spread of methicillin-resistant Staphylococcus aureus (MRSA)?

Wearing an N95 mask while in the room of a patient with airborne precautions.

Wearing a facemask while in the room of a patient with droplet precautions.

Use of a separate disposable blood pressure cuff for any patient with a draining wound.

Use of strict hand washing measures once in every 8-hour work shift.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Wearing an N95 mask is appropriate for airborne precautions, such as tuberculosis, but not specifically for MRSA, which requires contact precautions.

Choice B rationale
Wearing a facemask is suitable for droplet precautions, such as influenza, but MRSA is primarily spread through direct contact, not droplets.
Choice C rationale
Using a separate disposable blood pressure cuff for patients with draining wounds helps prevent the spread of MRSA. MRSA can be transmitted via contaminated medical equipment.
Choice D rationale
Strict hand washing measures are essential but should be performed more frequently than once every 8-hour shift. Hand hygiene should be practiced before and after patient contact.

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Correct Answer is A

Explanation

Choice A rationale
Enlarged liver (hepatomegaly) and peripheral edema are common clinical manifestations of right heart failure (RHF). RHF leads to congestion of systemic circulation, causing fluid accumulation in the liver and peripheral tissues.
Choice B rationale
Crackles in the lungs are more commonly associated with left-sided heart failure, where fluid backs up into the pulmonary circulation, leading to pulmonary edema.
Choice C rationale
A dry hacking cough is not a typical symptom of right heart failure. It is more commonly associated with respiratory conditions such as asthma or bronchitis.
Choice D rationale
Altered mentation with pinpoint pupils is not a characteristic of right heart failure. These symptoms are more indicative of neurological conditions or opioid overdose.

A. Post-renal acute kidney injury (AKI). B. Diabetes insipidus (DI). C. Syndrome of inappropriate antidiuretic hormone (SIADH). D. Congestive heart failure (CHF).

Correct Answer is D

Explanation

Choice A rationale
Post-renal acute kidney injury (AKI) is caused by obstruction of urine flow, leading to decreased urine output, but it does not typically cause crackles in the lungs.
Choice B rationale
Diabetes insipidus (DI) is characterized by excessive urination and thirst due to a deficiency of antidiuretic hormone (ADH), but it does not cause crackles in the lungs.
Choice C rationale
Syndrome of inappropriate antidiuretic hormone (SIADH) involves excessive release of ADH, leading to water retention and hyponatremia, but it does not cause crackles in the lungs.
Choice D rationale
Congestive heart failure (CHF) can lead to fluid accumulation in the lungs (crackles) and decreased urine output due to poor cardiac function and renal perfusion.

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Which infection control measure, by the nurse, reduces the potential spread of methicillin-resistant Staphylococcus aureus (MRSA)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which clinical manifestations would the nurse expect to find during their assessment of a patient with right heart failure (RHF)?

Correct Answer is A

Explanation

A nurse is caring for a client with chronic kidney disease (CKD) who has elevated intracranial pressure (ICP). While assessing the client, the nurse hears crackles in the lungs and notes a decrease in urine output.Which complication has the client likely developed?

Correct Answer is D

Explanation

A nurse is assessing a client with a temperature of 38°C (100.4°F) and notes a red, swollen area on the client’s leg. Which condition is the client most likely experiencing?

A man, diagnosed with alcoholic liver disease and cirrhosis, presents to his healthcare provider for treatment. He is complaining of increased blood glucose, blurred vision, and cannot remember his birth date or age. The nurse notes that he has asterixis. These signs are most likely due to:

A patient, who is on complete bed rest following extensive surgery, begins to complain of chest pain and shortness of breath with hemoptysis. His SO2 measures 90%. The nurse recognizes that the patient is most likely exhibiting signs and symptoms of which condition?

A nurse caring for a patient with unstable angina will most likely need to give medications to accomplish which desirable objective?

A nurse is assessing a client with a history of chronic obstructive pulmonary disease (COPD). Which of the following findings is most concerning?

A nurse is assessing a client with a temperature of 39°C (102.2°F) and a blood pressure of 90/60 mmHg. Which condition is the client most likely experiencing?

A nurse has identified a fluid volume deficit in the patient who has suffered prolonged vomiting and diarrhea. Which assessment data is most important in identifying that the patient may be developing prerenal acute kidney injury (AKI)?