Exhibits
Which 3 other interventions can the practical nurse (PN) initiate to limit the spread of methicillin-resistant Staphylococcus aureus (MRSA)?
Use a client-specific stethoscope.
Wipe the medication cart with bleach after bringing it into the room.
Measure the client's temperature with a disposable thermometer.
Change gloves between different clients.
Pad the client's side rails with clean linens.
Correct Answer : A,C,D
A. Use a client-specific stethoscope.
Indicated: Using a client-specific stethoscope helps prevent the spread of MRSA between patients. Each client should have dedicated equipment to reduce cross-contamination.
B. Wipe the medication cart with bleach after bringing it into the room.
Not Indicated: While disinfection of surfaces is important, the cart should be cleaned according to hospital protocol, which may involve different cleaning agents. Bleach is not typically used for medication carts and might not be the standard protocol.
C. Measure the client's temperature with a disposable thermometer.
Indicated: Using a disposable thermometer or single-use covers for thermometers prevents the transmission of MRSA to other patients. This practice helps maintain infection control.
D. Change gloves between different clients.
Indicated: Gloves should be changed between patients to prevent the spread of MRSA. This is a standard infection control practice to avoid cross-contamination.
E. Pad the client's side rails with clean linens.
Not Indicated: While padding the side rails may be done for client comfort or safety, it does not specifically address the control of MRSA spread and is not a direct infection control measure for MRSA.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A warm sleeping environment may exacerbate pruritus by increasing skin dryness and irritation. Cool, comfortable environments are generally better for clients with pruritus.
B. Keeping fingernails trimmed short helps prevent skin damage and infection caused by scratching. This is a practical and effective measure to manage pruritus.
C. Discouraging the use of skin lubricants is not advisable as they can help soothe and moisturize dry, itchy skin. Emollients and moisturizers are often recommended to manage pruritus.
D. Advising against any type of tub bath is not necessary. Instead, the use of lukewarm baths with added colloidal oatmeal or other soothing agents can help reduce pruritus.
Correct Answer is ["B","C","E"]
Explanation
A. Thrombocytopenia
Monitoring for thrombocytopenia is not directly related to the treatment of fluid volume deficit. While it is important to watch for any blood-related issues, thrombocytopenia is not a common concern specifically due to the administration of isotonic fluids like 0.9% sodium chloride. This condition would not be a primary focus in this scenario.
B. Pulmonary edema
The client should be monitored for pulmonary edema as a potential complication of fluid resuscitation. Administering large volumes of isotonic fluids can lead to fluid overload, which may cause pulmonary edema. This is especially important given the presence of pneumonia and the client's symptoms of shortness of breath and crackles in the lung fields.
C. Hypokalemia
Hypokalemia should be monitored as a potential complication of isotonic fluid administration. Although 0.9% sodium chloride does not contain potassium, patients receiving IV fluids for a significant period may develop electrolyte imbalances, including hypokalemia. Monitoring serum electrolytes is necessary to address such imbalances.
D. Alkalosis
Alkalosis is less likely to occur with isotonic fluids like 0.9% sodium chloride. This type of fluid generally does not cause acid-base imbalances such as alkalosis. The treatment for fluid volume deficit is not expected to lead to alkalosis, which is more commonly associated with metabolic alkalosis from other sources.
E. Phlebitis
Phlebitis should be monitored due to the presence of a peripheral IV access device. Long-term or large-volume infusions can irritate the vein, leading to inflammation or phlebitis. Regular inspection of the IV site for redness, swelling, or pain is necessary to prevent and manage this complication.
F. Hyponatremia
Hyponatremia is not a direct concern with isotonic fluids like 0.9% sodium chloride, as these fluids maintain sodium levels without causing a dilution effect. Monitoring sodium levels is generally more relevant in cases where hypotonic fluids are used.
G. Diarrhea and vomiting
Diarrhea and vomiting are not directly related to isotonic fluid administration. Although these symptoms can contribute to fluid volume deficits, they are not a common complication of fluid resuscitation.
H. Hyperglycemia
Hyperglycemia is not a concern with isotonic fluids like 0.9% sodium chloride. Hyperglycemia is more associated with fluids containing glucose, such as dextrose solutions. Therefore, monitoring for hyperglycemia is not necessary in this context
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