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.
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- 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 A
Explanation
A. Utilizing a friend's computer keyboard: Indirect transmission occurs when pathogens are transmitted via inanimate objects, such as keyboards, doorknobs, or utensils. If the friend's computer keyboard is contaminated with pathogens, the patient could contract an illness by touching it.
B. Talking directly to someone coughing: This is an example of direct transmission, where pathogens are transmitted through close contact with an infected person's respiratory secretions.
C. Standing next to a person with a varicella (chickenpox) infection: This is an example of direct transmission, as varicella is spread through respiratory droplets.
D. Walking past an individual coughing and sneezing: This is also an example of direct transmission, as respiratory droplets containing pathogens can land on the nurse and lead to infection if inhaled or touched.
Correct Answer is A
Explanation
A. Nonadherent dressing: Nonadherent dressings are suitable for small skin tears in older adult clients because they prevent the dressing from sticking to the wound bed, minimizing trauma during dressing changes.
B. Paste: Paste dressings are typically used for wound packing or for managing exuding wounds, not for small skin tears.
C. Moist, sterile gauze: While moist, sterile gauze can be used for wound dressings, it may adhere to the wound bed, causing further trauma during dressing changes.
D. Duoderm: Duoderm is a type of hydrocolloid dressing used for moderate to heavily exuding wounds, not for small skin tears.
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