A nurse is performing an admission assessment for a male client scheduled for the removal of an internal fixation device from a previous ankle fracture. The client informs the nurse that he was recently treated with intravenous vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which of the following actions should the nurse take? (Select all that apply.)
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.
Obtaining a sputum specimen for culture and sensitivity
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Creatinine is not a relevant laboratory test for the nurse to monitor, as this reflects renal function and is not affected by naproxen or arthritis. This is a distractor choice.
Choice B: Serum calcium is not a pertinent laboratory test for the nurse to monitor, as this indicates bone metabolism and is not related to naproxen or arthritis. This is another distractor choice.
Choice C: Erythrocyte sedimentation rate is not an important laboratory test for the nurse to monitor, as this measures inflammation and is not influenced by naproxen or stomach pain. This is another distractor choice.
Choice D: Hemoglobin is an essential laboratory test for the nurse to monitor, as this shows blood oxygen-carrying capacity and can be reduced by naproxen-induced gastrointestinal bleeding, which can cause stomach pain, weakness, and fatigue. Therefore, this is the correct choice.
Correct Answer is B
Explanation
Choice A reason: Explaining to the client that the dosage has been changed is not a safe action because it may not be true. The nurse should not assume that the prescribed dosage is correct or different from the previous one without verifying it with the healthcare provider or the medication record.
Choice C reason: Informing him that he may refuse the medication and documenting whether or not he takes it is not a responsible action because it does not address the issue of dosage discrepancy. The nurse should respect the client's right to refuse medication, but should also educate him about the benefits and risks of taking or not taking it. The nurse should also try to resolve any barriers or concerns that may affect the client's adherence to medication.
Choice D reason: Telling him to take the medication then verifying the dosage at the next healthcare team meeting is not a timely action because it may cause harm or complications to the client. The nurse should not administer any medication without checking its accuracy and appropriateness for the client. The nurse should also report and document any medication incidents as soon as possible.
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