A client who is paraplegic is admitted with a foul smelling drainage from a sacral ulcer. The client is suspected to have a methicillin resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Use standard precautions and wear a mask.

Institute contact precautions for staff and visitors.

Send wound drainage for culture and sensitivity.

Explain the purpose of a low bacteria diet.

Monitor the client's white blood cell count.

Answer and Explanation

Correct Answer : B,C,E

A. Use standard precautions and wear a mask.

While standard precautions should always be followed to prevent the spread of infection, wearing a mask is not specifically indicated for MRSA unless there is a risk of respiratory transmission. Contact precautions are more appropriate for MRSA.

B. Institute contact precautions for staff and visitors.

Contact precautions are necessary to prevent the spread of MRSA, a highly contagious bacteria. This involves using gloves and gowns when entering the client's room to prevent transmission of the bacteria to others.

C. Send wound drainage for culture and sensitivity.

Culturing the wound drainage helps identify the specific bacteria causing the infection and determines the most effective antibiotics for treatment (sensitivity testing).

D. Explain the purpose of a low bacteria diet.

A low bacteria diet is not typically indicated for managing MRSA infections. Instead, the focus should be on wound care, antibiotic therapy, and infection control measures to address the MRSA infection.

E. Monitor the client's white blood cell count.

Monitoring the white blood cell count helps assess the client's immune response and the severity of the infection. Elevated white blood cell counts may indicate an active infection and the need for further intervention.

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Correct Answer is C

Explanation

A. Risk for infection:

Neuropathy can compromise the ability to detect injuries or wounds on the feet. Consequently, there's a risk of wounds going unnoticed, becoming infected, and leading to serious complications. While preventing infection is important, the primary concern in this scenario is preventing the occurrence of wounds or skin breakdown in the first place.

B. Impaired physical mobility:

Impaired physical mobility may be a concern for clients with neuropathy, especially if it affects their ability to walk or perform activities of daily living. However, in this scenario, the client is reporting increasing numbness and tingling in the lower extremities, indicating a sensory issue rather than a motor one. Therefore, while physical mobility is important, it may not be the immediate priority for promoting foot care in this case.

C. Risk for impaired skin integrity:

This option addresses the potential risk of skin breakdown or damage due to decreased sensation in the lower extremities, which is characteristic of neuropathy. With increasing numbness and tingling, there's a higher risk that the client may not be able to perceive injuries or pressure points, leading to skin damage or ulceration. Preventing skin integrity issues is crucial to avoid complications such as infections or wounds.

D. Self-care deficit:

Neuropathy can indeed impact a person's ability to perform self-care activities, including foot care. However, the priority in this scenario is to prevent complications related to neuropathy, such as skin integrity issues, rather than addressing deficits in self-care abilities. While self-care education and support may be necessary in the long term, immediate intervention to prevent skin breakdown takes precedence.

A. Suctions secretions from the posterior pharynx. B. Tests for a gag reflex before performing oral care. C. Places the client in a supine position. D. Uses an oral airway to keep the teeth apart.

Correct Answer is C

Explanation

A. Suctions secretions from the posterior pharynx:

Suctioning secretions from the posterior pharynx is an appropriate action to maintain airway patency and prevent aspiration in an unconscious client. This action indicates proper understanding of oral care principles.

B. Tests for a gag reflex before performing oral care:

Testing for a gag reflex before performing oral care is an important safety measure, especially in unconscious clients, to prevent aspiration or airway obstruction. This action indicates proper assessment and consideration of the client's protective reflexes.

C. Places the client in a supine position:

Placing an unconscious client in a supine position during oral care can increase the risk of aspiration, as it may impair the client's ability to manage oral secretions. The preferred position for oral care in unconscious clients is typically a side-lying position to facilitate drainage of oral secretions and reduce the risk of aspiration.

D. Uses an oral airway to keep the teeth apart:

Using an oral airway to keep the teeth apart is not a standard practice for oral care in unconscious clients and may not be necessary. Proper positioning of the client's head and jaw manipulation can often provide adequate access for oral care without the need for an oral airway.

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A client who is paraplegic is admitted with a foul smelling drainage from a sacral ulcer. The client is suspected to have a methicillin resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

Correct Answer is C

Explanation

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

Correct Answer is C

Explanation

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