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 D

Explanation

A. Endogenous Infection: Endogenous infections originate from the client's own microbiota and typically do not involve medical interventions such as urinary catheterization.
B. Systemic Infection: Systemic infections affect the entire body and may not necessarily be related to the urinary tract.
C. Exogenous Infection: Exogenous infections originate from sources outside the client's body.
While the urinary tract infection could be caused by bacteria from the environment, it is more specifically categorized as a healthcare-associated infection (HAI) due to the indwelling urinary catheter being a risk factor.
D. Health Care-Associated Infection: A healthcare-associated infection (HAI) occurs as a result of healthcare interventions and can include infections related to urinary catheterization, surgery, or other medical procedures.

A. A person with diabetes who requires hospitalization for cellulitis. B. Pneumonia in a hospitalized patient. C. Chronic urinary tract infection for a homebound patient. D. A sexually transmitted infection in a healthy young adult.

Correct Answer is B

Explanation

A. A person with diabetes who requires hospitalization for cellulitis: Cellulitis may not necessarily be a healthcare-associated infection unless it developed as a complication during the hospitalization.
B. Pneumonia in a hospitalized patient: Pneumonia acquired during a hospital stay is considered a healthcare-associated infection (HAI) because it develops after 48 hours of hospital admission.
C. Chronic urinary tract infection for a homebound patient: A chronic urinary tract infection in a homebound patient is not automatically considered a healthcare-associated infection unless it can be directly linked to healthcare interventions or devices.
D. A sexually transmitted infection in a healthy young adult: Sexually transmitted infections are not healthcare-associated infections as they are typically acquired through sexual contact rather than healthcare settings.

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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 inserts an indwelling urinary catheter for a client who is preoperative. Three days later, the client develops a urinary tract infection. The nurse should identify that the client has which of the following types of infections?

Correct Answer is D

Explanation

Which of the following infections would the nurse recognize as being a health care-associated infection?

Correct Answer is B

Explanation

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?

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 nurse in a provider's office is collecting data from a client who has skin lesions. The nurse notes that the lesions are 2.5 cm in size, elevated, solid, and deep. The nurse should document the findings as which of the following skin lesions?

The nurse is collecting a culture of a wound. During the procedure, the patient asks what is a culture? Which of the following is the best response by the nurse to explain why she is culturing the wound?

A nurse is working in a dermatology clinic. The provider orders a skin biopsy, and you need to educate the client on the purpose of a skin biopsy. Which of the following is indicative of a skin biopsy?

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

A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?

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.