A male client is admitted for the removal of an internal fixation device that was inserted for a fractured ankle. During the client's admission history, he tells the nurse that he recently received vancomycin for a methicillin-resistant Staphylococcus aureus (MRS

Continue to monitor the client for signs of an infection.

Call the healthcare provider for a prescription for linezolid.

Collect multiple sets of blood cultures for MRSA screening.

Place the client on contact transmission precautions.

Answer and Explanation

Correct Answer : A,C,D

Choice A reason: This is a correct answer because continuing to monitor the client for signs of an infection is important to detect any recurrence or complication of MRSA infection. MRSA is a type of bacteria that is resistant to many antibiotics and can cause serious skin, soft tissue, bone, joint, or bloodstream infections. The nurse should assess the client's vital signs, wound appearance, pain level, and laboratory results.

Choice B reason: This is not a correct answer because calling the healthcare provider for a prescription for linezolid is not necessary unless the client has an active MRSA infection that requires treatment. Linezolid is an antibiotic that can be used to treat MRSA infections, but it has potential side effects and interactions that need to be considered. The nurse should not prescribe or administer antibiotics without a valid order.

Choice C reason: This is a correct answer because collecting multiple sets of blood cultures for MRSA screening is important to identify any asymptomatic bacteremia or sepsis that could result from MRSA infection. MRSA can enter the bloodstream through wounds, catheters, or surgical sites and cause life-threatening complications such as endocarditis, osteomyelitis, or pneumonia. The nurse should obtain blood samples from different sites and times and send them to the laboratory for analysis.

Choice D reason: This is a correct answer because placing the client on contact transmission precautions is important to prevent the spread of MRSA to other clients, staff, or visitors. Contact transmission precautions include wearing gloves and gowns when entering the client's room, using dedicated or disposable equipment, and performing hand hygiene before and after contact with the client or their environment.

Choice E reason: This is not a correct answer because obtaining a sputum specimen for culture and sensitivity is not relevant to the client's history of MRSA wound infection. Sputum culture and sensitivity is a test that can be used to diagnose respiratory infections caused by bacteria, fungi, or viruses. The nurse should only obtain a sputum specimen if the client has signs or symptoms of a respiratory infection, such as cough, fever, chest pain, or dyspnea.

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Correct Answer is D

Explanation

Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.

Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.

Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.

A. Consume foods with saturated fats. B. Walk 30 minutes per day. C. Use a salt substitute. D. Keep a food diary. E. Eat more canned vegetables. F. Include oatmeal for breakfast.

Correct Answer is ["A","E"]

Explanation

Choice A: Consuming foods with saturated fats is not a healthy lifestyle change for a client with coronary artery disease, as this can increase the level of cholesterol and triglycerides in the blood, which can lead to plaque formation and narrowing of the arteries. Therefore, this statement indicates that the client needs additional education.

Choice B: Walking 30 minutes per day is a beneficial lifestyle change for a client with coronary artery disease, as this can improve the blood circulation, lower the blood pressure, and reduce the risk of heart attack and stroke. Therefore, this statement does not indicate that the client needs additional education.

Choice C: Using a salt substitute is a helpful lifestyle change for a client with coronary artery disease, as this can reduce the sodium intake, which can lower the blood pressure and prevent fluid retention. Therefore, this statement does not indicate that the client needs additional education.

Choice D: Keeping a food diary is a useful lifestyle change for a client with coronary artery disease, as this can help the client monitor their calorie intake, portion size, and nutritional quality of their food. This can also help the client identify and avoid unhealthy food choices. Therefore, this statement does not indicate that the client needs additional education.

Choice E: Eating more canned vegetables is not a good lifestyle change for a client with coronary artery disease, as canned vegetables often contain high amounts of sodium, which can raise the blood pressure and worsen the condition. Therefore, this statement indicates that the client needs additional education.

Choice F: Including oatmeal for breakfast is an advantageous lifestyle change for a client with coronary artery disease, as oatmeal contains soluble fiber, which can lower the cholesterol level and prevent plaque formation in the arteries. Therefore, this statement does not indicate that the client needs additional education.

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A male client is admitted for the removal of an internal fixation device that was inserted for a fractured ankle. During the client's admission history, he tells the nurse that he recently received vancomycin for a methicillin-resistant Staphylococcus aureus (MRS

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Correct Answer is D

Explanation

The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

Correct Answer is ["A","E"]

Explanation

The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3-year-old son for wetting his pants. What initial action should the nurse take?

A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet?

The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply)

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD.?

A client with obsessive-compulsive disorder (OCD. is repeatedly washing the top of the same table. Which intervention should the nurse implement?

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donninggloves and a gown to assist the client. Which action should the nurse take?

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider?

A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?