Nokea
The nurse is caring for a client with a sacral wound infected with Methicillin-resistant staphylococcus aureus. Which personal protective equipment (PPE) is necessary to care for this client? Select all that apply.
- A. Gloves
- B. N95 respirator
- C. Surgical Mask
- D. Goggles
- E. Gown
Correct Answer: A,E
Rationale: MRSA requires contact precautions, including gloves and a gown. N95 respirators, surgical masks, and goggles are not needed unless aerosol-generating procedures are performed.
You may also like to solve these questions
The nurse provides discharge teaching to a client prescribed a cane for left-sided weakness. Which instruction should the nurse provide?
- A. Advance the cane along with your stronger leg.
- B. Remove the rubber tip when going upstairs.
- C. Measure the height of the cane to your elbow.
- D. Secure the cane in your right hand.
Correct Answer: D
Rationale: The cane is held in the right hand (stronger side) for left-sided weakness to support the weaker leg. The stronger leg moves first, rubber tips stay on, and height is measured to the greater trochanter.
The nurse is participating in a committee reviewing strategies to reduce falls in older adults. Which of the following recommendations by the nurse would be appropriate to make?
- A. Increase the availability of bedside commodes
- B. Recommend the occupational therapist assess the client for mobility and safety
- C. Reduce environmental lighting, especially at night
- D. Remove grab bars from the bathrooms
Correct Answer: A,B
Rationale: Bedside commodes and occupational therapy assessments reduce fall risk by improving access and mobility. Reducing lighting and removing grab bars increase fall risk.
Which of the following clients would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain?
- A. A 36-year-old client with abdominal pain
- B. A 56-year-old client with a below-the-knee amputation and phantom limb pain
- C. A 76-year-old client with terminal cancer
- D. An 84-year-old client with severe arthritis
Correct Answer: B
Rationale: Contralateral stimulation, rubbing the opposite limb, is effective for phantom limb pain by altering pain perception. It is less effective for visceral, cancer, or arthritic pain.
The nurse observes that a fire has ignited in the client's room. After removing the client from the room, the nurse should then
- A. activate the fire alarm.
- B. extinguish the fire.
- C. contact the nursing supervisor.
- D. close the door to the client's room.
Correct Answer: A
Rationale: Following the RACE protocol (Rescue, Alarm, Contain, Extinguish), after rescuing the client, the nurse should activate the fire alarm to alert others and initiate emergency response.
The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with contact precautions? Select all that apply.
- A. Hepatitis C
- B. Cryptococcal meningitis
- C. Clostridium difficile
- D. Scabies
- E. Rheumatic fever
- F. Botulism
- G. Hepatitis B
Correct Answer: C,D
Rationale: Clostridium difficile and scabies require contact precautions due to direct or indirect transmission. Others require standard precautions.