A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? (Select all that apply.)

Use standard precautions and wear a mask.

Monitor the client's white blood cell count.

Institute contact precautions for staff and visitors.

Send wound drainage for culture and sensitivity.

Explain the purpose of a low-bacteria diet.

Answer and Explanation

Correct Answer : B,C,D

A)   Incorrect- Standard precautions are used for all clients to prevent the spread of infections.
However, in the case of MRSA, contact precautions are needed due to the risk of direct transmission through physical contact.
B)   Correct- Monitoring the white blood cell count is important to assess for signs of infection, as an elevated count might indicate an ongoing inflammatory response.
C)   Correct- Foul-smelling drainage from an incision with suspected MRSA indicates a potential infection. Contact precautions are appropriate for MRSA, which include wearing gloves and gowns when entering the client's room to prevent the spread of the bacteria.
D)   Correct- Sending wound drainage for culture and sensitivity helps identify the specific microorganisms causing the infection and guides appropriate antibiotic treatment.
E)   Incorrect- A low-bacteria diet is not relevant to the situation. MRSA is caused by a bacterium, not by dietary factors. The focus should be on infection control measures and appropriate medical interventions.

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Correct Answer is B

Explanation

Shortness of breath on exertion in a client with a history of chronic obstructive pulmonary disease (COPD) and pneumonia indicates increased respiratory distress and compromised lung function. It suggests that the client is experiencing difficulty breathing even with minimal physical exertion. This finding may indicate worsening respiratory status, increased oxygen demand, and inadequate oxygenation. The nurse should take immediate action to address the shortness of breath, which may involve providing supplemental oxygen, initiating or adjusting bronchodilator medications, and monitoring the client's respiratory status closely. Prompt intervention is crucial to ensure adequate oxygenation and prevent respiratory failure.

While the other assessment findings (bilateral diffuse wheezing, temperature of 100.5 °F, and yellow expectorated sputum) are also important and require attention, the shortness of breath on exertion poses the greatest immediate risk and necessitates immediate intervention to address the client's respiratory distress.

A. Explain to the UAP that changes in a client's condition should be reported immediately. B. Advise the UAP to stop providing care so the nurse can assess the client's condition. C C. Ask the UAP to position the client so the oral medications can be administered. D. Determine why the UAP did not notify the nurse of the change in the client's condition.

Correct Answer is B

Explanation

A) Incorrect- While it's important for UAPs to report changes in a client's condition, the immediate priority is to assess and address the deteriorating condition of the client. The nurse's first action should be to stop the current care being provided and assess the client.
B) Correct- In this situation, the priority is to ensure the safety and well-being of the client. The client's deteriorated condition needs to be assessed promptly by a licensed nurse to determine the appropriate interventions. Stopping the care being provided by the unlicensed assistive personnel (UAP) allows the nurse to focus on the client's immediate needs.
C) Incorrect- Administering oral medications is not the immediate priority in this situation. The client's deteriorating condition takes precedence over administering medications.
D) Incorrect- While investigating the situation and addressing communication gaps is important, the first priority is to assess and address the client's current condition. The nurse needs to take immediate action to ensure the client's safety and well-being.

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A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). 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

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include: heart rate 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg. Which assessment finding warrants the most immediate intervention by the nurse?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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