This is the edited text:
What is a priority nursing intervention for a client with lupus who is receiving steroids for a flareup?
The nurse washes their hands before entering the room.
Assist with the enhancement of social wellbeing by providing activities.
Assessing the client’s support system.
Ensure privacy by keeping the door always closed.
The Correct Answer is A
Choice A reason: This is the priority nursing intervention because it helps to prevent infection, which is a major complication and risk factor for mortality in clients with lupus. Lupus is an autoimmune disease that causes inflammation and damage to various organs and tissues. Steroids are used to reduce inflammation and suppress the immune system, but they also increase the susceptibility to infection. The nurse should wash their hands before and after contact with the client and follow standard precautions to reduce the transmission of microorganisms.
Choice B reason: This is not the priority nursing intervention, but it is a good intervention to promote the psychosocial health of the client. Lupus can affect the client's selfesteem, mood, and social relationships, especially during a flareup, which is a period of increased symptoms and activity of the disease. The nurse should assist with the enhancement of social wellbeing by providing activities that are appropriate for the client's physical and mental condition, such as reading, listening to music, or talking with friends and family.
Choice C reason: This is not the priority nursing intervention, but it is a good intervention to evaluate the client's coping and support resources. Lupus can be a chronic and unpredictable disease that can cause stress, anxiety, and depression in the client. The nurse should assess the client's support system, such as family, friends, or community groups, that can provide emotional, practical, and financial assistance to the client. The nurse should also refer the client to counseling, support groups, or other services as needed.
Choice D reason: This is not the priority nursing intervention, but it is a good intervention to respect the client's dignity and autonomy. Lupus can affect the client's appearance, mobility, and independence, which can make them feel vulnerable and embarrassed. The nurse should ensure privacy by keeping the door always closed, unless the client requests otherwise, and by knocking and asking for permission before entering the room. The nurse should also cover the client with a blanket or gown and expose only the necessary body parts during assessment or procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Obtaining a PAPR mask is not a step in preparing a sterile field. A PAPR mask is a powered airpurifying respirator that protects the wearer from airborne contaminants. It is not required for setting up a sterile field, unless the client has a highly infectious disease.
Choice B reason: Do not turn away from the sterile field is a step in preparing a sterile field. Turning away from the sterile field can contaminate the field or the items on it. The nurse should always face the sterile field and keep it in view.
Choice C reason: Add items to the sterile field by dropping them gently is a step in preparing a sterile field. Dropping items gently onto the sterile field prevents splashing or touching the field or the items. The nurse should open the sterile packages away from the field and drop the items close to the edge of the field.
Choice D reason: Covering the sterile field once it is set up is not a step in preparing a sterile field. Covering the sterile field can compromise its sterility and create moisture that can harbor microorganisms. The nurse should not cover the sterile field unless it is necessary to move it or store it for later use.
Choice E reason: Preparing the client before setting up the sterile field is a step in preparing a sterile field. Preparing the client involves explaining the procedure, obtaining consent, providing privacy, and positioning the client. The nurse should prepare the client before setting up the sterile field to avoid leaving the field unattended or exposing it to the client's body fluids.
Correct Answer is A
Explanation
Choice A reason: Wearing a gown is the correct answer, because it is the appropriate PPE for contact precautions, which are required for clients who have MRSA. MRSA is a type of bacteria that is resistant to many antibiotics and can cause serious infections in the skin, blood, lungs, or other organs. MRSA can be transmitted by direct or indirect contact with the infected wound or contaminated surfaces. Wearing a gown can protect the nurse's clothing and skin from exposure to MRSA.
Choice B reason: Wearing sterile gloves is not the correct answer, because it is not the appropriate PPE for contact precautions, which are required for clients who have MRSA. Sterile gloves are used for sterile procedures, such as inserting a catheter or changing a dressing, not for routine assessments, such as checking the pulse. Wearing sterile gloves can be wasteful and unnecessary, and it does not provide adequate protection from MRSA.
Choice C reason: Wearing a PAPR mask is not the correct answer, because it is not the appropriate PPE for contact precautions, which are required for clients who have MRSA. PAPR stands for powered airpurifying respirator, and it is a type of mask that filters the air and provides positive pressure to the wearer. PAPR masks are used for airborne precautions, which are required for clients who have diseases that can be spread through the air, such as tuberculosis or measles, not for clients who have MRSA.
Choice D reason: Wearing a surgical mask is not the correct answer, because it is not the appropriate PPE for contact precautions, which are required for clients who have MRSA. Surgical masks are used for droplet precautions, which are required for clients who have diseases that can be spread through respiratory droplets, such as influenza or pertussis, not for clients who have MRSA.
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