The nurse plans care for a client with a wound positive for methicillin-resistant Staphylococcus aureus (MRSA). What action should the nurse include in the care of this client?

All visitors should wear hair and shoe covers.

All visitors should wear a gown and gloves.

All visitors should wear goggles and gloves.

All visitors should wear an N95 mask and gown.

Answer and Explanation

The Correct Answer is B

A. All visitors should wear hair and shoe covers: Hair and shoe covers are not part of standard contact precautions for MRSA. Transmission occurs primarily through direct contact with contaminated surfaces or wounds rather than hair or footwear. Routine use of these items does not reduce MRSA spread.

B. All visitors should wear a gown and gloves: MRSA requires contact precautions to prevent transmission via hands and clothing. Gowns protect clothing from contamination, and gloves reduce direct contact with infectious material. This practice is consistent with infection prevention guidelines for multidrug-resistant organisms.

C. All visitors should wear goggles and gloves: Eye protection is reserved for situations with a risk of splashing or spraying of body fluids. MRSA wound care does not typically pose this risk during routine contact. Goggles are not routinely indicated.

D. All visitors should wear an N95 mask and gown: N95 respirators are used for airborne pathogens such as tuberculosis, not contact-spread organisms like MRSA. Respiratory protection is unnecessary unless aerosol-generating procedures are involved.

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Correct Answer is C

Explanation

A. Open the sterile drape and place it on the table: Opening sterile supplies before preparing the environment increases the risk of contamination. The surface must be clean, dry, and positioned appropriately before any sterile items are opened. Environmental preparation precedes establishing the sterile field.

B. Put on sterile personal protective equipment: Sterile gloves and PPE are donned after the sterile field is set up, not before. Donning them too early increases the risk of contamination during setup. Hand hygiene and environment preparation come first.

C. Clean a work surface and raise it to waist level: The work surface must be disinfected and positioned at or above waist level to maintain visibility and prevent contamination. Sterile fields kept below waist level are considered contaminated. Preparing the environment is the first step in sterile setup.

D. Arrange sterile instruments on the sterile field: Sterile instruments are handled only after the sterile field has been properly established. Placing instruments occurs later in the setup sequence. This action depends on prior preparation of the field.

A. “I will use the cane to support all of my weight when walking." B. "I will make sure my elbow is bent slightly when I hold the cane." C. "I will move the strong leg up the stairs first, then the cane, and then the weak leg." D. “I will hold the cane on the weak side of my body to support it."

Correct Answer is B

Explanation

A. “I will use the cane to support all of my weight when walking.": A cane is meant to provide partial support and improve balance, not bear the client’s full weight. Relying entirely on the cane can cause instability and increase the risk of falls.

B. "I will make sure my elbow is bent slightly when I hold the cane.": Proper cane use requires a slight elbow flexion of about 20–30 degrees. This position ensures optimal support, reduces strain on the shoulder and wrist, and promotes safe ambulation.

C. "I will move the strong leg up the stairs first, then the cane, and then the weak leg.": When using a cane, it should move simultaneously with the weaker leg while ascending or descending stairs to provide support. Moving the strong leg first without coordinating the cane can compromise safety.

D. “I will hold the cane on the weak side of my body to support it.": The cane should be held on the strong side to provide counterbalance and allow the weaker leg to bear weight safely. Holding it on the weak side decreases stability and increases fall risk.

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The nurse plans care for a client with a wound positive for methicillin-resistant Staphylococcus aureus (MRSA). What action should the nurse include in the care of this client?

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Naxlex Comprehensive Predictor Exams

The nurse plans to perform a sterile procedure on a client at the bedside. Which action should the nurse plan to take first when setting up their sterile field?

Correct Answer is C

Explanation

Review the electronic health record. The nurse is preparing the client for discharge. After the nurse provides education about the use of a cane, which statement by the client indicates understanding?

Correct Answer is B

Explanation

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