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 supplemental oxygen is the priority intervention for a client with COPD who has an oxygen saturation of 88% on room air. This low oxygen saturation indicates hypoxemia, which requires immediate correction to prevent further respiratory distress.
Choice B rationale
Encouraging the client to use an incentive spirometer is important for lung expansion and preventing atelectasis, but it is not the priority intervention in this scenario. The immediate concern is to correct the hypoxemia.
Choice C rationale
Administering a bronchodilator as prescribed is important for managing COPD symptoms, but the priority intervention is to correct the hypoxemia by administering supplemental oxygen.
Choice D rationale
Positioning the client in high Fowler’s position can help improve breathing, but the priority intervention is to correct the hypoxemia by administering supplemental oxygen.
Correct Answer is B
Explanation
Choice A rationale
Decreasing the secretion of thyroid stimulating hormone (TSH) by the pituitary gland is not a compensatory response to fluid volume deficit. TSH primarily regulates thyroid function and metabolism, and its secretion is not directly related to fluid balance or osmolality.
Choice B rationale
Increasing renin-angiotensin-aldosterone system (RAAS) activity by the kidneys is the body’s primary compensatory response to fluid volume deficit. When there is a decrease in blood volume or blood pressure, the kidneys release renin, which activates the RAAS. This system increases the reabsorption of sodium and water in the kidneys, leading to an increase in blood volume and blood pressure.
Choice C rationale
Decreasing the secretion of cortisol by the adrenal gland is not a compensatory response to fluid volume deficit. Cortisol is a stress hormone that helps regulate metabolism, immune response, and other functions, but it is not directly involved in fluid balance.
Choice D rationale
Increasing the secretion of natriuretic peptides by the heart is a response to fluid overload, not fluid deficit. Natriuretic peptides promote the excretion of sodium and water by the kidneys, which helps reduce blood volume and pressure. This response is opposite to what is needed in a fluid volume deficit situation.