A nurse is assisting with the care of a client with the history below:

Exhibits

A nurse is caring for the client. Which of the following actions should the nurse take? Select (2) answers that apply.

Wear a protective gown while caring for the client.

Place the client in a private room.

Wear an N-95 respirator while caring for the client.

Place the client in a negative pressure room.

Place a mask on the client when they leave their room.

Answer and Explanation

Correct Answer : A,B

A. Wearing a protective gown is necessary when caring for a client with C. difficile to prevent the spread of spores and protect the nurse from contact with contaminated surfaces.
B. Placing the client in a private room helps to isolate the infection and prevent transmission to other patients, which is essential in managing C. difficile infections.
C. An N-95 respirator is not required for C. difficile as the primary mode of transmission is via the fecal-oral route, not through airborne particles.
D. A negative pressure room is used for airborne infections like tuberculosis, not for C. difficile. C. difficile requires contact precautions rather than airborne precautions.
E. A mask is not necessary for the client with C. difficile when leaving the room; instead, hand hygiene and proper gowning are essential for preventing the spread of the infection.

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Correct Answer is D

Explanation

A. Skin lesions are seen as solid predictors of the general health state: While skin lesions can provide valuable information about a patient's health, they are not the only indicator. Changes in the skin can indicate various health conditions, not just lesions.
B. The patient's psychological health is best predicted by the skin: While changes in the skin can sometimes be associated with psychological health conditions, they are not the sole predictors. Psychological health is assessed through a comprehensive evaluation, including observation, interview, and assessment tools.
C. Detection of skin cancer is the only reason to assess the client's skin: While skin cancer detection is an important aspect of skin assessment, it is not the only reason. Skin assessment provides valuable information about overall health, hydration status, circulation, and potential systemic conditions.
D. The skin is a good communicator regarding the client's overall health: The skin can provide valuable clues about a patient's overall health status. Changes in skin color, texture, moisture, and integrity can indicate underlying health conditions, nutritional deficiencies, circulation problems, or systemic diseases. Therefore, focusing on any changes noted in the patient's skin is essential for comprehensive assessment and early detection of potential health issues.

A. Place the client in a private room. B. Administer intravenous vancomycin C. Wear a cover gown when caring for the client. D. Restrict fluid intake. E. Initiate supplemental oxygen.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

Place the client in a private room.
- Essential: Placing the client in a private room helps prevent the spread of MRSA to other patients and reduces the risk of transmission.
Administer intravenous vancomycin.
- Essential: Vancomycin is an appropriate antibiotic choice for treating MRSA infections, and administering it intravenously allows for effective delivery of the medication to combat the infection.
Wear a cover gown when caring for the client.
- Essential: Wearing a cover gown provides an additional barrier of protection against potential contact with the client's infected wound and helps prevent transmission of MRSA to healthcare workers and other patients.
Restrict fluid intake.
- Contraindicated: Restricting fluid intake is not indicated in this scenario. Adequate hydration is essential for supporting the body's immune response and maintaining organ function, especially in the presence of fever and infection.
Initiate supplemental oxygen.
- Nonessential: Supplemental oxygen is not indicated based on the client's oxygen saturation of 96% on room air. Oxygen supplementation is typically reserved for clients who are hypoxic or experiencing respiratory distress, which is not the case here.

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A nurse is assisting with the care of a client with the history below: Exhibits A nurse is caring for the client. Which of the following actions should the nurse take? Select (2) answers that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse in a healthcare provider's (HCP's) office is reassessing a patient's skin and making a comparison with the information from the patient's last visit. For which reason does the nurse focus on any changes noted in the patient's skin?

Correct Answer is D

Explanation

A nurse is caring for a client. Exhibits For each potential nursing action, click to specify if the action is essential. nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

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A nurse is preparing to administer vancomycin 250 mg PO. The amount available is vancomycin 125 mg/ capsule. How many capsules should the nurse administer to the client with each dose? (Round to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

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A nurse is assisting with the care of a client with the history below:

Exhibits

A nurse is caring for the client. Which of the following actions should the nurse take? Select (2) answers that apply.