A nurse is teaching a newly licensed nurse about the care of a client who has a methicillin-resistant Staphylococcus aureus. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will tell the client's visitors to wear a mask when they are within 3 feet of the client."

"I will place the client in a private room."

"I will wear an N95 respirator mask when caring for the client."

"I will remove my gown before my gloves after providing client care."

Answer and Explanation

The Correct Answer is B

Choice A Reason:
"I will tell the client's visitors to wear a mask when they are within 3 feet of the client" is not typically required for MRSA. Visitors may need to adhere to standard hand hygiene practices, but wearing a mask within a certain distance of the client is not a standard precaution for MRSA.
Choice B Reason:
"I will place the client in a private room." This statement is correct because clients with MRSA are often placed in private rooms to prevent the spread of the infection to other clients. Private rooms help to reduce the risk of transmission to other individuals in the healthcare facility.
Choice C Reason:
"I will wear an N95 respirator mask when caring for the client" is generally not necessary for routine care of clients with MRSA. N95 respirators are typically used when dealing with airborne infectious diseases. Standard precautions, including gloves and gowns, are usually sufficient for MRSA.
Choice D Reason:
"I will remove my gown before my gloves after providing client care" is not the recommended sequence. The correct sequence is to remove gloves first to avoid contaminating the hands while removing the gown. This practice is important for infection control.

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Correct Answer is D

Explanation

Choice A Reason:
Cool skin is not a typical sign of hyperglycemia. Hyperglycemia can cause skin to be warm or hot, but cool skin is more often associated with conditions like hypoglycemia (low blood sugar).
Choice B Reason:
Shakiness is more commonly associated with hypoglycemia (low blood sugar) rather than hyperglycemia.
Choice C Reason:
Confusion can occur in both hyperglycemia and hypoglycemia, so it is not a specific indicator of hyperglycemia on its own.
Choice D Reason:
Thirst. Hyperglycemia is associated with increased thirst (polydipsia) as the body attempts to rid itself of excess glucose by increasing urine output. This leads to dehydration, which triggers thirst.

A. Verify the count total of the controlled substance after removing the amount needed. B. Ask a second nurse to record her signature when wasting any unused portion of the controlled substance. C. Report any discrepancy in the count total of the controlled substance after administration. D. Place the wasted portion of the controlled substance in the sharp container.

Correct Answer is C

Explanation

Choice A Reason:
Verifying the count total of the controlled substance after removing the amount needed is a good practice but does not directly address reporting discrepancies or irregularities.
Choice B Reason:
Asking a second nurse to record her signature when wasting any unused portion of the controlled substance is related to the documentation process when wasting unused portions, not the initial administration. It is important but not the primary action for administering the medication.
Choice C Reason:
Report any discrepancy in the count total of the controlled substance after administration. This is an essential step to address any discrepancies or irregularities in the count total, which helps maintain accurate records and prevent diversion or unauthorized access to the controlled substance.
Choice D Reason:
Placing the wasted portion of the controlled substance in the sharp container is the proper disposal method for sharps and medical waste but does not address the initial administration of the controlled substance.

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A nurse is teaching a newly licensed nurse about the care of a client who has a methicillin-resistant Staphylococcus aureus. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

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Naxlex Comprehensive Predictor Exams

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