A nurse is caring for a client.
For each potential nursing action, click to specify if the action is essential. nonessential, or contraindicated for the client.
Place the client in a private room.
Administer intravenous vancomycin
Wear a cover gown when caring for the client.
Restrict fluid intake.
Initiate supplemental oxygen.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}
- 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Povidone-iodine: Povidone-iodine is an antiseptic agent used for skin disinfection but is not recommended for routine hand hygiene, especially in cases of Clostridium difficile infection.
B. Alcohol-based antiseptic: While alcohol-based hand sanitizers are effective for most routine hand hygiene situations, they may not be sufficient for removing spores of Clostridium difficile. Soap and water are preferred for hand hygiene in cases of C. difficile infection.
C. Chlorhexidine: Chlorhexidine is an antiseptic agent commonly used for skin disinfection, but like alcohol-based hand sanitizers, it may not effectively remove C. difficile spores. Soap and water are preferred.
D. Soap and water: Soap and water are recommended for hand hygiene in cases of Clostridium difficile infection because mechanical friction from hand washing helps physically remove
spores from the hands.
Correct Answer is B
Explanation
A. Bullae: Bullae are fluid-filled lesions larger than 0.5 cm in diameter.
B. Nodules: Nodules are elevated, solid lesions deeper and firmer than papules, typically larger than 0.5 cm in diameter.
C. Papules: Papules are elevated, solid lesions smaller than 0.5 cm in diameter.
D. Macules: Macules are flat, colored lesions that are smaller than 1 cm in diameter.
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