Which infection control measure, by the nurse, reduces the potential spread of methicillin-resistant Staphylococcus aureus (MRSA)?
Wearing an N95 mask while in the room of a patient with airborne precautions.
Wearing a facemask while in the room of a patient with droplet precautions.
Use of a separate disposable blood pressure cuff for any patient with a draining wound.
Use of strict hand washing measures once in every 8-hour work shift.
The Correct Answer is C
Choice A rationale
Wearing an N95 mask is appropriate for airborne precautions, such as tuberculosis, but not specifically for MRSA, which requires contact precautions.
Choice B rationale
Wearing a facemask is suitable for droplet precautions, such as influenza, but MRSA is primarily spread through direct contact, not droplets.
Choice C rationale
Using a separate disposable blood pressure cuff for patients with draining wounds helps prevent the spread of MRSA. MRSA can be transmitted via contaminated medical equipment.
Choice D rationale
Strict hand washing measures are essential but should be performed more frequently than once every 8-hour shift. Hand hygiene should be practiced before and after patient contact.
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Correct Answer is A
Explanation
Choice A rationale
Administering antihypertensive medication as prescribed is the priority action for a client with a history of hypertension presenting with severe headache, blurred vision, and confusion. These symptoms suggest a hypertensive crisis, which requires immediate blood pressure reduction to prevent further complications.
Choice B rationale
Preparing the client for a lumbar puncture is not the priority action in this scenario. While a lumbar puncture may be necessary to rule out other conditions, the immediate concern is to manage the hypertensive crisis.
Choice C rationale
Initiating seizure precautions is important if the client is at risk of seizures, but the priority action is to address the hypertensive crisis by administering antihypertensive medication.vv
Choice D rationale
Monitoring the client’s blood glucose levels is important for overall health management, but it is not the priority action in this scenario. The immediate concern is to manage the hypertensive crisis.
Correct Answer is C
Explanation
Choice A rationale
Urine specific gravity of 1.029 indicates concentrated urine, which is common in dehydration but not specific to prerenal AKI. It reflects the kidney’s ability to concentrate urine in response to fluid deficit.
Choice B rationale
BUN of 28 mg/dL can indicate dehydration or renal impairment. However, it is not as specific as creatinine in diagnosing prerenal AKI. BUN can be elevated due to other factors like high protein intake or gastrointestinal bleeding.
Choice C rationale
Creatinine of 2.4 mg/dL is a critical indicator of kidney function. Elevated creatinine levels are more specific to renal impairment, including prerenal AKI, as they reflect the kidney’s ability to filter waste products.
Choice D rationale
Dry mucous membranes are a sign of dehydration but are not specific to prerenal AKI. They indicate fluid volume deficit but do not directly reflect kidney function.