A 57-year old female client is admitted to the hospital with left upper arm open wound infection (methicillin-resistant Staphylococcus aureus (MRSA]) and cellulitis.
Indicate whether the nursing actions listed below are Indicated (appropriate or necessary). Contraindicated (could be harmful), or Non-essential (make no difference or are not necessary) for the client's care at this time.
Place the client on Contact Precautions.
Apply cold compress on her left upper arm.
Elevate the client's arm on a pillow.
Take a wound culture every shift to determine if the infection is improving.
Have RN initiate IV access for the client to receive fluids and antibiotic therapy.
Administer subcutaneous sodium heparin every 12 hours.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"C"}}
A. Placing the client on Contact Precautions is appropriate to prevent the transmission of MRSA to other patients and healthcare workers.
B. Applying a cold compress may worsen tissue damage and compromise blood flow, which can exacerbate the wound infection and cellulitis.
C. Elevating the client's arm can help reduce swelling and improve circulation, aiding in the resolution of cellulitis.
D. Taking a wound culture every shift is not necessary or useful, as it can be painful for the client and does not provide timely information on the infection status. A wound culture is usually done once before starting antibiotic therapy and then repeated only if there is no improvement or signs of worsening.
E. Initiating IV access for fluid and antibiotic therapy is necessary for treating the systemic infection caused by MRSA and cellulitis.
F. Subcutaneous sodium heparin is an anticoagulant that prevents blood clots, but it is not indicated for this client unless they have a history or risk of thromboembolic events, such as deep vein thrombosis or pulmonary embolism.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Droplet precautions are used for diseases transmitted via respiratory droplets, such as influenza or pertussis.
B. Neutropenic precautions are implemented to protect clients with compromised immune systems from exposure to pathogens, typically in the environment.
C. Airborne precautions are used for diseases transmitted via small droplet nuclei that remain suspended in the air, such as tuberculosis or measles.
D. Contact precautions are appropriate for clients infected or colonized with multidrug-resistant organisms like VRE, requiring the use of gloves and gowns when providing care to prevent transmission.
Correct Answer is D
Explanation
A. Normal joint wear and tear typically do not result in bony enlargements, deviation of fingers, or hard, painless joints.
B. Osteomyelitis is a bone infection and would present with symptoms such as fever, localized pain, swelling, and redness over the affected bone, rather than bony enlargements of the joints.
C. Uric acid deposits are associated with conditions like gout and would typically manifest as acute attacks of severe pain, redness, and swelling in the affected joint, rather than the chronic, painless joint deformities seen in the scenario described.
D. Rheumatoid Arthritis (RA) is a chronic autoimmune disorder characterized by inflammation of the synovium, leading to joint deformities, bony enlargements, and deviation of fingers. Joints affected by RA are typically hard, painless, and may exhibit ulnar deviation.
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