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 D
Explanation
Gastric residual refers to the volume of formula or feeding remaining in the stomach after a previous feeding. A gastric residual of 300 mL is considered high and may indicate delayed gastric emptying or impaired gastrointestinal motility.
The other findings mentioned are within normal range or expected in the context of enteral feeding. A blood glucose level of 110 mg/dL is within the acceptable range. Having diarrhea once in a 24-hour period is not unusual and can be attributed to various factors. A weight gain of 0.91 kg (2 lb) in 2 days can be expected due to increased fluid intake with enteral feeding and should be monitored for further trends. However, a high gastric residual is a significant finding that warrants further assessment and intervention.
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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