The nurse is preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA. Which PPE items should the nurse plan to use? (Select all that apply.)

Shoe covers

Gown

N95 respirator

Surgical mask

Gloves

Answer and Explanation

Correct Answer : B,D,E

A reason:

Shoe covers are not typically required for standard precautions when dealing with MRSA-infected wounds. They are used in specific scenarios to prevent environmental contamination.

B reason:

Wearing a gown is essential to protect the nurse's clothing and skin from potential contamination with MRSA.

C reason:

An N95 respirator is not necessary unless there is a concern about airborne transmission, which is not the case with MRSA in a draining wound.

D reason:

A surgical mask may be used to protect the nurse from any potential splashes or to prevent respiratory droplets from contaminating the wound area.

E reason:

Gloves are essential to protect the nurse's hands from contamination and prevent the spread of MRSA. They should be worn during any contact with the wound or contaminated linens.

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Correct Answer is D

Explanation

A reason:

Urinary frequency refers to the need to urinate more often than usual. While it can be a symptom of a urinary tract infection (UTI), it is not characterized by dark, cloudy urine with an unpleasant odor.

B reason:

Urinary incontinence is the loss of bladder control, which can lead to accidental leakage of urine. It is not directly associated with the described urine characteristics.

C reason:

Urinary retention is the inability to empty the bladder completely. It can lead to distended bladder and discomfort, but it does not typically cause the urine to become dark, cloudy, or foul-smelling.

D reason:

A urinary tract infection is correct. UTIs often cause dark amber, cloudy urine with an unpleasant odor due to the presence of bacteria and white blood cells in the urine.

A. Apply wrist and leg restraints to the client. B. Move the client to a room closer to the nurses' station. C. Administer medication to sedate the client. D. Call the family and ask them to stay with the client.

Correct Answer is B

Explanation

A reason:

Applying wrist and leg restraints is an extreme measure and should be used only as a last resort when all other interventions have failed. Restraints can cause physical and psychological harm and should be avoided if possible.

B reason:

Moving the client to a room closer to the nurses' station is the best option. This allows for closer monitoring and quick intervention if the client's condition worsens or if they become a danger to themselves.

C reason:

Administering medication to sedate the client is not the first action to take. Sedation can mask symptoms and lead to further complications. Non-pharmacologic interventions should be considered first.

D reason:

Calling the family and asking them to stay with the client may provide comfort and help reduce confusion, but it is not a substitute for proper medical intervention and monitoring. The priority is to ensure the client is in a safe environment where they can be closely monitored by medical staff.

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The nurse is preparing to change the linens on the bed of a client who has a draining sacral wound infected by MRSA. Which PPE items should the nurse plan to use? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following?

Correct Answer is D

Explanation

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

Correct Answer is B

Explanation

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