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.
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 C
Explanation
Choice A: 18%. This is not the correct percentage, as it only accounts for one lower extremity. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so both lower extremities would account for 18% x 2 = 36%.
Choice B: 27%. This is not the correct percentage, as it only accounts for one and a half lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so one and a half lower extremities would account for 9% x 3 = 27%.
Choice C: 36%. This is the correct percentage, as it accounts for both lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so both lower extremities would account for 9% x 4 = 36%.
Choice D: 45%. This is not the correct percentage, as it accounts for more than both lower extremities. According to the rule of nines, each lower extremity accounts for 9% of body surface area on both anterior and posterior sides, so more than both lower extremities would account for more than 9% x 4 = 36%.
Correct Answer is C
Explanation
Choice A: Providing bedside equipment for transmission and protective precautions is not the first action that the nurse should implement, as this is a standard precaution that should be already in place for all clients in the critical care unit. This is a distractor choice.
Choice B: Evaluating daily serum electrolytes and hydration status is not the first action that the nurse should implement, as this is a routine assessment that can be done later after addressing the immediate problem of infection. This is another distractor choice.
Choice C: Culturing sputum, urine, burn wound, and all intravenous access sites is the first action that the nurse should implement, as this can help identify the source and type of infection, which can guide the appropriate antibiotic therapy and prevent further complications. Therefore, this is the correct choice.
Choice D: Implementing central line-associated bloodstream infection (CLABSI) protocols is not the first action that the nurse should implement, as this is a preventive measure that may not be applicable for this client who already has SIRS. This is another distractor choice.
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