Nokea
The nurse reviews wound culture results and learns that an assigned client has methicillin-resistant Staphylococcus aureus (MRSA) in a wound bed. Which type of transmission-based precautions should the nurse implement for this client?
- A. Enteric precautions
- B. Droplet precautions
- C. Contact precautions
- D. Airborne precautions
Correct Answer: C
Rationale: Contact precautions include standard precautions and require the use of barrier precautions such as gloves and goggles. Contact precautions are used for clients who have diarrhea, draining wounds, or methicillin-resistant infections. The goal of these precautions is to eliminate disease transmission resulting either from direct contact with the client or from indirect contact through inanimate objects or surfaces that the pathogen has contaminated, such as instruments, linens, dressing materials, or hands. Enteric precautions are initiated if the organism is transmitted via the gastrointestinal tract. Droplet and airborne precautions are used if the organism is transmitted via the respiratory tract.
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The nurse inserts an indwelling urinary catheter into a client. As the catheter moves into the bladder, urine begins to flow into the tubing. Which action should the nurse implement next?
- A. Inflate the balloon with water.
- B. Secure the catheter to the client.
- C. Measure the initial urine output.
- D. Advance the catheter 2.5 to 5cm .
Correct Answer: D
Rationale: The balloon of a urinary catheter is behind the opening at the insertion tip, so the nurse inserts the catheter 2.5 to 5cm further after urine begins to flow so as to provide sufficient space to inflate the balloon. The balloon is not inflated as soon as urine appears because the balloon could be located in the urethra. After the insertion procedure and inflation of the balloon, the nurse secures the catheter to the client's leg and then measures the initial urine output.
A registered nurse (RN) is orienting an unlicensed assistive personnel (UAP) to the clinical nursing unit. The RN determines that the UAP needs further teaching if which action is performed by the UAP during a routine hand-washing procedure?
- A. Keeps hands lower than elbows
- B. Dries from forearm down to fingers
- C. Washes continuously for 10 to 15 seconds
- D. Uses 3 to 5mL of soap from the dispenser
Correct Answer: C
Rationale: The UAP needs further teaching if they wash continuously for only 10 to 15 seconds, as proper hand-washing requires at least 15 to 20 seconds of continuous scrubbing to effectively remove pathogens. Keeping hands lower than elbows is correct to allow water to flow from the cleaner area (forearms) to the dirtier area (hands). Drying from forearm to fingers is appropriate to prevent recontamination of hands. Using 3 to 5 mL of soap is adequate for effective cleaning.
A client who is admitted to the hospital for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The unlicensed assistive personnel (UAP) assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. The nurse tells the UAP that which intervention is needed for infection control?
- A. Enteric precautions should be instituted for the client.
- B. Gloves and mask should be used when in the client's room.
- C. Contact isolation should be initiated because the disease is highly contagious.
- D. Standard precautions are sufficient because the disease is transmitted sexually.
Correct Answer: D
Rationale: Chlamydia is a sexually transmitted infection. Caregivers cannot acquire the disease during administration of care, and standard precautions are the only measure that needs to be used. Recognizing the necessary precautions will help you in identifying the remaining options as incorrect.
The nurse is caring for a pregnant client with preeclampsia who is receiving a prescribed intravenous (IV) infusion of magnesium sulfate. To provide a safe environment, the nurse should ensure that which priority item is available?
- A. Tongue blade
- B. Percussion hammer
- C. Calcium gluconate injection
- D. Potassium chloride injection
Correct Answer: C
Rationale: Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle. Toxic effects of magnesium sulfate may cause loss of deep tendon reflexes, heart block, respiratory paralysis, and cardiac arrest. The antidote for magnesium sulfate is calcium gluconate and should be available. An airway rather than a tongue blade is also an appropriate item. A percussion hammer may be important to assess reflexes but is not the priority item. Potassium chloride is not related to the administration of magnesium sulfate.
The nurse observes that a postoperative client has episodes of extreme agitation. Which is the best nursing measure to implement to prevent escalating the agitation?
- A. Gently hold the client's hand while speaking.
- B. Wait to approach until the client's agitation has subsided.
- C. Speak in a calm tone while moving slowly toward the client.
- D. Communicate with the client from the entrance to the room.
Correct Answer: C
Rationale: Speaking and moving slowly toward the client will prevent the client from becoming further agitated because any sudden moves or speaking too quickly may cause the client to have a violent episode. Holding the client's hand can be misinterpreted by a client to mean restraint. If the client's agitation is not addressed, it is likely to increase; therefore, waiting for the agitation to subside is not a suitable option. Remaining at the entrance of the room can make the client feel alienated.