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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A reason:
Having the client wear a mask is correct. This helps to contain respiratory droplets and prevent the spread of tuberculosis during transport.
B reason:
Notifying the x-ray department about the need for airborne precautions is important but not the primary precaution for transporting the client.
C reason:
Wearing a filtration mask and gloves by the nurse during transport is protective for the nurse but does not prevent the client from spreading the infection during transport.
D reason:
Asking the x-ray technician to come to the client's room for a portable x-ray can be considered but is not always practical. The primary focus is ensuring the client wears a mask during transport to minimize infection risk to others.
Correct Answer is C
Explanation
A reason:
Determining the time the client last received pain medication is important, but it should be done after assessing the current pain level. The nurse needs to know the severity of the pain to decide the next steps.
B reason:
Measuring the client's vital signs, including temperature, is also important, especially to rule out complications like infection. However, addressing the client's immediate pain should take priority to provide relief and then proceed with further assessments.
C reason:
Asking the client to rate her pain on a scale from 0 to 10 is correct. This provides a clear understanding of the pain's intensity, which is essential for determining the appropriate intervention. It allows the nurse to gauge the severity of the pain and respond accordingly.
D reason:
Repositioning the client and offering a back rub can help alleviate discomfort, but these actions should follow the pain assessment to ensure the interventions are appropriate based on the pain's severity and nature.
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