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 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.
Correct Answer is B
Explanation
A. Thickening of the epidermis: The epidermis tends to thin rather than thicken with aging.
Thinning of the epidermis can lead to increased vulnerability to injury and slower wound healing.
B. Thinning of the epidermis: Thinning of the epidermis is a common age-related change in the skin. This thinning can result in a decreased barrier function, making the skin more susceptible to damage and infection.
C. Oiliness of the skin: Older adults often experience a decrease in oil production, leading to drier skin rather than oilier skin.
D. Increased elasticity of the skin: With aging, the skin tends to lose elasticity, resulting in sagging and wrinkles rather than increased elasticity.
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