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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["9"]
Explanation
Here are the steps you can follow to calculate the infusion pump flow rate:
Step 1: Calculate the prescribed dose in mcg/min
- Dose per weight: 2 mcg/kg/min * 60 kg = 120 mcg/min
Step 2: Convert the concentration in the IV bag to mcg/mL
- Convert mg to mcg: 200 mg * 1000 mcg/mg = 200,000 mcg
- Concentration: 200,000 mcg / 250 mL = 800 mcg/mL
Step 3: Calculate the flow rate in mL/min
- Flow rate: 120 mcg/min / 800 mcg/mL = 0.15 mL/min
Step 4: Convert the flow rate to mL/hour
- Hour conversion: 0.15 mL/min * 60 min/hour = 9 mL/hour
Therefore, the nurse should program the infusion pump to deliver 9 mL/hour.
Correct Answer is A
Explanation
A) Correct- Hematocrit values below the reference range during pregnancy could indicate anemia, which requires further evaluation and intervention. The other findings can be attributed to normal physiological changes during pregnancy (elevated total T4, heart rate increase) or can be common findings (systolic murmur).
B) Incorrect - A heart rate of 92 beats per minute is within the normal range for pregnancy due to increased blood volume and hormonal changes.
C) Incorrect - A systolic murmur can be a common finding during pregnancy due to increased cardiac output.
D) Incorrect - An elevated total T4 can be a normal finding during pregnancy due to hormonal changes.
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