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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 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.

Correct Answer is A

Explanation

A. Place all clients who have manifestations on contact precautions: Given the suspicion of Clostridium difficile infection due to the development of watery diarrhea in multiple clients, it is appropriate to place these clients on contact precautions until the diagnosis is confirmed or ruled out. Contact precautions help prevent the spread of the infection by requiring healthcare workers to wear gloves and gowns when entering the room.
B. Obtain stool cultures from all clients on the nursing unit: While obtaining stool cultures may be necessary to confirm the diagnosis of C. difficile infection, implementing contact precautions is more immediate and necessary to prevent transmission.
C. Request the providers to initiate antibiotic therapy for every client on the unit: Initiating antibiotic therapy for every client on the unit without confirmation of C. difficile infection is not appropriate and may contribute to antibiotic resistance.

D. Perform hand hygiene with an alcohol-based agent: Hand hygiene is essential in preventing the spread of infection, but in the case of C. difficile, handwashing with soap and water is recommended over alcohol-based hand sanitizers due to the spore-forming nature of the bacteria.

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