A client with draining skin lesions of the lower extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions 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.
Explain the purpose of a low bacteria diet
Monitor the client's white blood cell count.
Correct Answer : B,D
A. Use standard precautions and wear a mask:
The use of standard precautions is appropriate for general care to prevent the transmission of infectious agents. However, specific to MRSA, additional precautions are needed. Wearing a mask is generally not necessary unless the client has respiratory symptoms that warrant respiratory precautions.
B. Institute contact precautions for staff and visitors:
This is a correct intervention. Contact precautions involve using gowns and gloves when providing care to prevent the transmission of MRSA. It is important for both healthcare staff and visitors to adhere to contact precautions to reduce the risk of spreading the infection.
C. Explain the purpose of a low bacteria diet:
The purpose of a low bacteria diet is generally unrelated to the management of MRSA. Low bacteria diets are often recommended for individuals with compromised immune systems to reduce the risk of foodborne infections. However, it may not be directly applicable to MRSA management.
D. Monitor the client's white blood cell count:
Monitoring the white blood cell count is a relevant intervention. An elevated white blood cell count may indicate an ongoing infection or an inflammatory response. Regular monitoring helps assess the client's immune response and the potential severity of the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Activity level of bowel sounds:
Bowel sounds are important to assess, but they may not directly influence or be influenced by the abdominal pain associated with chronic pancreatitis.
B. Eating patterns and dietary intake.
Clients with chronic pancreatitis often experience abdominal pain exacerbated by the intake of food, especially fatty meals. Monitoring the client's eating patterns and dietary intake is crucial for identifying triggers that may worsen the abdominal pain. By understanding the relationship between food intake and pain, the nurse can provide guidance on dietary modifications to help manage the symptoms.
C. Level and amount of physical activity:
While physical activity is important for overall health, it may not be the primary factor contributing to or alleviating the abdominal pain in a client with chronic pancreatitis.
D. Color and consistency of feces:
Monitoring the color and consistency of feces is important for assessing pancreatic function, but it may not be the most immediate factor to address in the context of managing abdominal pain. Dietary patterns are more directly related to pain management in this case.
Correct Answer is D
Explanation
A. Encourage regular turning:
While turning is important for preventing complications like pressure ulcers, in this acute situation, addressing fluid imbalance and potential sepsis take precedence.
B. Monitor skin for breakdown:
Monitoring for skin breakdown is essential but is not the most critical intervention at this moment.
C. Assess wound drainage daily:
Daily assessment of wound drainage is important for evaluating the status of the surgical site. However, in this situation of potential anastomosis leakage with signs of systemic infection and hypotension, immediate interventions to stabilize the client's condition are of higher priority.
D. Strict IV fluid replacement:
This is the correct answer. The client is displaying signs of systemic infection (fever) and possible sepsis (tachycardia, hypotension), which might be due to an anastomosis leakage following gastric bypass surgery. Ensuring adequate IV fluid replacement is crucial to address hypotension, maintain perfusion, and support hemodynamic stability in this critical situation.
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