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.

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.

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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Correct Answer is A

Explanation

A. Perform hand hygiene before, during, and after direct contact with the client: Hand hygiene is one of the most effective strategies to interrupt the transmission of infections. It helps prevent the spread of pathogens from one person to another, reducing the risk of healthcare-associated infections.
B. Encourage the client to consume a diet high in protein: While proper nutrition is important for overall health and immune function, it does not directly address the transmission of the client's infection.

C. Change the client's bed linens each day: Changing bed linens regularly is important for maintaining cleanliness and comfort but is not sufficient to interrupt the transmission of infection.

D. Place the client in a room with positive pressure airflow: Positive pressure airflow rooms are typically used for patients with compromised immune systems to protect them from airborne pathogens. This strategy is not applicable for all types of infections and may not be necessary for every client with an infection.

A. Exudate B. Pain C. Hyperthermia D. Hardening of the tissue

Correct Answer is C

Explanation

A. Exudate: Exudate refers to the fluid, such as pus or serum, that is discharged from a wound.
While exudate may be present in infected wounds, it is not a systemic response.
B. Pain: Pain is a localized response to tissue injury and may be present in infected wounds, but it is not a systemic response.
C. Hyperthermia: Hyperthermia, or an elevated body temperature (fever), is a common systemic response to infection, including wound infections. It indicates the body's immune response to the infection.
D. Hardening of the tissue: Hardening of the tissue, known as induration, may occur in infected wounds due to inflammation but is not a specific systemic response.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to interrupt the transmission of the client's infection?

Correct Answer is A

Explanation

The nurse is caring for a client with a wound on their leg. During the nurse's assessment, the client explains that he is not feeling well. The nurse knows that a systemic response to a wound infection would be?

Correct Answer is C

Explanation

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?

The nurse is taking care of a patient diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA). The nurse knows that this disease is difficult to treat and has a high mortality rate. Which medication would the nurse expect to be ordered to treat this infection?

A patient has been recently diagnosed with an upper respiratory infection. His brother arrives and would like to visit. The patient says he is not feeling strong enough to have visitors. Which symptom would indicate to the nurse that the client is developing a complication?

The nurse works in an office with a dermatologist. What equipment is most important to have readily available when a patient is undergoing skin testing for allergies?

Which of the following assessments should be performed to monitor for impaired tissue integrity?

A nurse is assessing an older adult client who has a urinary tract infection (UTI). Which of the following findings should the nurse identify as unique for this age group?

A nurse is caring for an older client and educating the student nurse on assessing the skin. The student nurse knows that an older client's skin is most likely to experience which of the following changes with aging?

Which of the following is an example of a reservoir in the chain of infection?

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.