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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.

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.

Answer and Explanation

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.


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Related Questions

Correct Answer is A

Explanation

A. Obtain a sputum culture: Obtaining a sputum culture helps identify the causative organism of pneumonia, which guides appropriate antibiotic therapy.
B. Cough and deep breathe every 6 hours: While coughing and deep breathing exercises are important for preventing complications such as atelectasis, they are not specific to pneumonia treatment and may not be appropriate for all patients with pneumonia.
C. Encourage fluid intake of 1500 mL/day: Adequate fluid intake is generally recommended for overall health but is not a specific intervention for pneumonia treatment.
D. Position the client prone: Positioning the client prone is not a standard intervention for pneumonia treatment. Depending on the severity and type of pneumonia, the client's positioning may vary, but prone positioning is not routinely recommended.

Correct Answer is B

Explanation

A. Place a N95 mask on the patient: Tuberculosis (TB) is an airborne infectious disease, and N95 masks are specifically designed to filter out airborne particles, including those that may carry TB bacteria. Therefore, placing an N95 mask on the patient helps prevent the spread of TB to others during transportation.

B. Place a surgical mask on the patient: While a surgical mask may provide some level of
protection, it is not as effective as an N95 mask in filtering out airborne particles, particularly those associated with TB transmission.
C. Be sure the patient is wearing a protective gown: Protective gowns are typically used to
prevent the transmission of infection through contact with body fluids or contaminated surfaces. However, in the case of TB, airborne precautions, including respiratory protection with masks, are more crucial.
D. Instruct the patient to wear gloves to radiology: Gloves are not necessary for respiratory protection against TB during transportation to radiology.

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