A nurse is caring for a patient with methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound and is about to check the patient’s pulse.
What precautions should the nurse take?
Wear sterile gloves.
Wear protective eyewear.
Wear clean gloves.
Wear an N95 respirator mask.
The Correct Answer is C
Choice A rationale
Sterile gloves are not necessary when checking a patient’s pulse. They are typically used for procedures that require aseptic technique, such as wound dressing changes or insertion of a central venous catheter.
Choice B rationale
Protective eyewear is used to protect the healthcare provider from splashes or sprays of blood, body fluids, secretions, or excretions. It is not necessary when checking a patient’s pulse.
Choice C rationale
Clean gloves should be worn when touching blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin. This includes when caring for a patient with MRSA in an abdominal wound.
Choice D rationale
An N95 respirator mask is used to protect the healthcare provider from airborne pathogens, such as tuberculosis. It is not necessary when checking a patient’s pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
0.9% sodium chloride, also known as normal saline, is an isotonic solution that is commonly used for hydration and to replace lost fluids. However, it does not provide any calories or nutrients, which are necessary for patients receiving TPN1.
Choice B rationale
Dextrose 10% in water (D10W) is the recommended solution to administer until the next TPN solution is available. This is a hypertonic fluid that provides dextrose to the patient, helping to maintain their blood glucose levels and reducing the risk of hypoglycemia.
Choice C rationale
3% sodium chloride is a hypertonic saline solution that is typically used to treat patients with severe hyponatremia (low sodium levels). It is not suitable as a replacement for TPN as it does not provide the necessary nutrients and can lead to hypernatremia (high sodium levels) if used inappropriately.
Choice D rationale
Lactated Ringer’s solution is an isotonic solution that is commonly used for fluid resuscitation in patients with significant fluid loss. While it does contain multiple electrolytes that mimic those found in plasma, it does not provide any calories or nutrients, making it unsuitable as a replacement for TPN1.
Correct Answer is A
Explanation
Choice A rationale
Donning sterile gloves before inserting the indwelling urinary catheter is a critical step to prevent infection. The urinary tract is normally sterile, and using sterile gloves helps maintain this sterility during the procedure.
Choice B rationale
Applying an oil-based lubricant to the indwelling urinary catheter is not recommended. Oil- based lubricants can damage latex catheters and increase the risk of infection. A water-soluble lubricant is typically used.
Choice C rationale
Using one cotton swab to clean the client’s genitalia is not sufficient. Proper cleaning and disinfection of the area are crucial to prevent introducing bacteria into the urinary tract during catheter insertion.
Choice D rationale
Testing the balloon on the indwelling urinary catheter before insertion is not typically done. The balloon is usually inflated with sterile water once the catheter is in place to ensure that it remains in the bladder.
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