A nurse is admitting a client who has a wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which of the following types of precautions should the nurse plan to initiate?
Protective.
Droplet.
Airborne.
Contact.
The Correct Answer is D
Choice A rationale:
Protective precautions (also known as reverse isolation) are implemented to protect clients with compromised immune systems from potential pathogens brought in by healthcare providers or visitors. This choice would be appropriate for clients who are highly susceptible to infections, but it's not the primary choice for managing a wound infected with MRSA.
Choice B rationale:
Droplet precautions are utilized for diseases spread by respiratory droplets. MRSA is primarily spread through direct contact with contaminated skin or objects. Therefore, droplet precautions are not the most appropriate choice for this scenario.
Choice C rationale:
Airborne precautions are designed for diseases that spread via small particles suspended in the air, such as tuberculosis. MRSA does not spread through the airborne route, so airborne precautions are not necessary for a wound infection with MRSA.
Choice D rationale:
Contact precautions are the correct choice when dealing with MRSA infections. MRSA is primarily transmitted through direct physical contact or contact with contaminated objects. By implementing contact precautions, the nurse can effectively prevent the spread of the infection to other clients and healthcare workers.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: d. Protective. Protective precautions are crucial for clients who have had an allogeneic hematopoietic stem-cell transplant due to their severely weakened immune systems.
Choice A reason:
Airborne precautions are used for infections that spread through the air, such as tuberculosis and measles. These infections require special ventilation and respiratory protection, which is not the primary concern for stem-cell transplant patients.
Choice B reason:
Contact precautions are used for infections spread by direct contact, like MRSA or C. difficile. These precautions involve wearing gloves and gowns but do not address the airborne or droplet risks that immunocompromised patients face.
Choice C reason:
Droplet precautions are for infections spread by large respiratory droplets, such as influenza or pertussis. While important, they do not provide the comprehensive protection needed for stem-cell transplant recipients.
Choice D reason:
Protective precautions involve placing the patient in a room with HEPA filtration and limiting visitors to minimize infection risk. This is essential for patients with compromised immune systems, such as those who have undergone allogeneic hematopoietic stem-cell transplants.
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale:
Dyspnea (shortness of breath) is a common finding in clients with emphysema. Emphysema is a chronic obstructive pulmonary disease characterized by the destruction of lung tissue, leading to reduced lung elasticity and airflow limitation, which can result in difficulty breathing.
Choice B rationale:
Clubbing of the fingers is another expected finding in clients with advanced emphysema. Clubbing is the swelling and rounding of the fingertips, often associated with chronic respiratory conditions. It is thought to be a result of chronic hypoxia and inadequate oxygenation.
Choice C rationale:
Deep respirations are not typically associated with emphysema. Clients with emphysema often exhibit shallow, rapid respirations due to the loss of lung tissue elasticity, which impairs the normal respiratory mechanics.
Choice D rationale:
Bradycardia (slow heart rate) is not a common finding in emphysema. Emphysema primarily affects the respiratory system and does not directly influence heart rate. Bradycardia could be related to other factors but is not a characteristic finding of emphysema.
Choice E rationale:
Barrel chest is a classic physical finding in clients with emphysema. It results from the hyperinflation of the lungs due to the trapping of air in the damaged alveoli. This gives the chest a rounded appearance, similar to the shape of a barrel.
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