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 C

Explanation

Choice A: Think about reasons the episodes occur. This is not the best instruction, as it may increase the anxiety level of the client. Thinking about reasons may trigger negative thoughts, emotions, or memories that can worsen the anxiety. The nurse should teach the client to focus on coping skills rather than causes.

Choice B: Center attention on positive upbeat music. This is not the best instruction, as it may not be effective for all clients. Listening to positive upbeat music may help distract or soothe some clients, but it may also irritate or annoy others. The nurse should teach the client to choose music that matches their mood and preference.

Choice C: Practice using muscle relaxation techniques. This is the best instruction, as it can reduce the physical symptoms of anxiety. Muscle relaxation techniques involve tensing and relaxing different muscle groups in a systematic way, which can lower blood pressure, heart rate, and breathing rate. The nurse should teach the client how to perform muscle relaxation techniques and practice them regularly.

Choice D: Find outlets for more social interaction. This is not the best instruction, as it may not be feasible or helpful for all clients. Finding outlets for more social interaction may help some clients feel supported or connected, but it may also stress or overwhelm others. The nurse should teach the client to seek social support that is appropriate and comfortable for them.

A. A 16-year-old client diagnosed with major depression who refuses to participate in group. B. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby. C. An 18-year-old client with antisocial behavior who is being yelled at by other clients. D. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.

Correct Answer is C

Explanation

Choice A reason: A 16-year-old client diagnosed with major depression who refuses to participate in group does not require the nurse's immediate attention. Depression is a mood disorder that causes persistent feelings of sadness, hopelessness, and loss of interest. Refusing to participate in group may indicate low motivation, social withdrawal, or poor self-esteem, which are common symptoms of depression. The nurse should respect the client's preference and offer alternative activities or individual therapy.

Choice B reason: A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby does not require the nurse's immediate attention. Bipolar disorder is a mood disorder that causes alternating episodes of mania and depression. Pacing around the lobby may indicate restlessness, agitation, or increased energy, which are common signs of mania. The nurse should monitor the client's behavior and mood and ensure safety and appropriate medication administration.

Choice D reason: A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack does not require the nurse's immediate attention. Anorexia nervosa is an eating disorder that causes extreme restriction of food intake and fear of weight gain. Refusing to eat the evening snack may indicate distorted body image, dietary rules, or anxiety, which are common factors of anorexia nervosa. The nurse should encourage the client to eat and provide support and 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 providing education to a client who experiences recurrent episodes of moderate anxiety to situations. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Correct Answer is C

Explanation

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

Correct Answer is C

Explanation

The nurse leading a cardiac team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse assign to the PN?

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

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

A male client reports to the on-call clinic nurse that he took two tablets of 10 mg lisinopril by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any chest pain at the moment or recently. Which action should the nurse take?

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse’s immediate attention?

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

The nurse is assigning care of a client with prostatitis to a practical nurse (PN). Which instruction should the nurse provide the PN regarding this client?

When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first?