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: Assessing pupillary response to light hourly is not related to dopamine administration. Dopamine does not affect the pupils or the cranial nerves that control them.
Choice B: Initiating seizure precautions is not necessary for a client receiving dopamine. Dopamine does not lower the seizure threshold or cause convulsions.
Choice C: Measuring urinary output every hour is an important intervention for a client receiving dopamine. Dopamine increases blood pressure and cardiac output, which improves renal perfusion and urine production. Urinary output is an indicator of the effectiveness of dopamine therapy and renal function.
Choice D: Monitoring serum potassium frequently is not directly related to dopamine administration. Dopamine does not affect potassium levels or cause hyperkalemia or hypokalemia. However, potassium levels may be affected by other factors such as fluid balance, renal function, and medications.
Correct Answer is ["30"]
Explanation
First, we need to find the concentration of insulin in the IV solution, which is the ratio of insulin units to saline volume. To do this, we use the given information that the IV solution contains 100 units in 250 ml. So, we divide 100 by 250 and get 0.4 units/ml.
Next, we need to calculate the infusion rate in ml/hour for the ordered dose of 12 units/hour. To do this, we use the ratio of insulin units to saline volume, which is 0.4 units/ml. So, we set up a proportion as follows:
0.4/1=12/x
To solve for x, we cross-multiply and get 0.4 x = 12. Then, we divide both sides by 0.4 and get x = 30. So, the infusion rate is 30 ml/hour.
Therefore, the nurse should program the infusion pump to deliver 30 ml/hour..
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