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 D

Explanation

A. Administering the medication to a client behind a closed curtain:

Administering medication behind a closed curtain is not necessarily a tort. However, it may be a breach of privacy depending on the circumstances and the client's preferences.

B. Enlisting security personnel to assist with restraining the client:

Enlisting security personnel to assist with restraining an agitated client is not inherently a tort. It may be necessary to ensure the safety of the client and healthcare providers, depending on the situation.

C. Informing a client that the medication being administered is a vitamin:

Misinforming a client about the medication being administered is not a tort, but it is unethical and can lead to potential harm if the client does not receive appropriate treatment.

D. Placing a client in restraints without having a healthcare provider's order:

This action constitutes a tort known as false imprisonment. Restraints should only be applied when ordered by a healthcare provider and when necessary to ensure the safety of the client or others. Placing a client in restraints without proper authorization can lead to physical and psychological harm and is a violation of the client's rights.

A. Warn the colleague that copying health information is unlawful. B. Send an email to facility administrators reporting the action. C. Communicate the colleague's activities to the unit charge nurse. D. Dispose the copies and continue with client care assignments.

Correct Answer is C

Explanation

A. Warn the colleague that copying health information is unlawful:

While informing the colleague about the unlawful nature of copying health information is important, it may not adequately address the potential breach of patient privacy and confidentiality. Additionally, the colleague may be aware of the laws but still engage in inappropriate behavior.

B. Send an email to facility administrators reporting the action:

Reporting the colleague's actions to facility administrators may be necessary, but it may not be the most immediate action to take. Informing the unit charge nurse allows for more immediate intervention and resolution within the unit.

C. Communicate the colleague's activities to the unit charge nurse:

This is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.

D. Dispose the copies and continue with client care assignments:

While disposing of the copies may prevent further unauthorized access to patient information, it does not address the issue of the colleague's inappropriate handling of the records. It's essential to report the incident to the appropriate authority for further investigation and follow-up.

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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.

Nursing Test Bank

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Correct Answer is D

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Correct Answer is C

Explanation

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