A nurse is caring for a patient who has undergone a small bowel resection and has a history of methicillin-resistant Staphylococcus aureus (MRSA).

Which nursing intervention is most crucial to minimize the risk of a MRSA recurrence in the postoperative wound?

Change the surgical dressing promptly when it becomes soiled.

Monitor for any increase in the white blood cell count.

Educate the family on the importance of adhering to contact precautions.

Always wear a face mask while performing wound care.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Changing the surgical dressing promptly when it becomes soiled is crucial to minimize the risk of a MRSA recurrence in the postoperative wound. A soiled dressing can become a medium for bacterial growth, including MRSA, and can potentially contaminate the wound.

Choice B rationale

Monitoring for any increase in the white blood cell count is important in detecting an infection, including a MRSA infection. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.

Choice C rationale

Educating the family on the importance of adhering to contact precautions is important in preventing the spread of MRSA. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.

Choice D rationale

Wearing a face mask while performing wound care can help prevent the spread of MRSA. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.

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Correct Answer is B

Explanation

Choice A rationale

While nausea and vomiting can be side effects of eye surgery, they are not typically associated with acute pain deep within the eye following laser trabeculoplasty. Therefore, administering an antiemetic would not address the client’s primary complaint.

Choice B rationale

Acute pain deep within the eye following laser trabeculoplasty is not a typical postoperative symptom and could indicate a complication such as increased intraocular pressure or inflammation. Therefore, the nurse should report this complaint to the surgeon immediately for further evaluation.

Choice C rationale

While eye shields can help reduce photosensitivity after eye surgery, they would not typically alleviate acute pain deep within the eye. Therefore, this action would not address the client’s primary complaint.

Choice D rationale

While prophylactic antibiotics can help prevent infection after eye surgery, they would not typically alleviate acute pain deep within the eye. Therefore, this action would not address the client’s primary complaint.

A. The right foot is cool to the touch and appears pale and blanched. B. The pressure dressing at the right femoral area is moist and oozing blood. C. The client’s blood pressure trend is downward, and the pulse is rapid and irregular. D. The pulse distal to the femoral artery is weaker on the left foot than the right foot.

Correct Answer is A

Explanation

Choice A rationale

The right foot being cool to the touch and appearing pale and blanched is a classic sign of arterial obstruction. After a cardiac catheterization via the right femoral artery, it’s possible that a clot or other obstruction could have formed, impeding blood flow to the right foot. This would cause the foot to become cool and pale due to lack of warm, oxygenated blood.

Choice B rationale

While a moist and oozing pressure dressing at the right femoral area could indicate a problem such as bleeding from the catheter insertion site, it does not specifically indicate arterial obstruction.

Choice C rationale

A downward trend in blood pressure and a rapid, irregular pulse could indicate many different problems, including shock, heart failure, or arrhythmias. However, these symptoms are not specific to arterial obstruction.

Choice D rationale

A weaker pulse distal to the femoral artery on the left foot compared to the right foot could indicate a problem with circulation to the left foot, but it does not indicate an obstruction in the right femoral artery.

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A nurse is caring for a patient who has undergone a small bowel resection and has a history of methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention is most crucial to minimize the risk of a MRSA recurrence in the postoperative wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye.Which action should the nurse take?

Correct Answer is B

Explanation

A client is two hours postoperative from a cardiac catheterization via the right femoral artery.Which assessment finding indicates arterial obstruction?

Correct Answer is A

Explanation

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A nurse is caring for a patient who has undergone a small bowel resection and has a history of methicillin-resistant Staphylococcus aureus (MRSA).

Which nursing intervention is most crucial to minimize the risk of a MRSA recurrence in the postoperative wound?