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 ["A","C"]

Explanation

Choice A rationale

The statement “This diagnosis means that I am crazy” requires follow-up teaching by the nurse. Mental health conditions do not equate to being “crazy”. It’s important to educate the client about the nature of their diagnosis and dispel any misconceptions.

Choice B rationale

The statement “Many people have the same response to a stressful situation as I am having right now” does not require follow-up teaching. It shows that the client understands that their reaction to stress is not uncommon.

Choice C rationale

The statement “I will probably need to be on medication for the rest of my life” requires follow-up teaching. While some conditions do require long-term medication, it’s not a certainty for all conditions. The duration of treatment can vary based on the individual’s response and the nature of their condition.

Choice D rationale

The statement “I can use holistic approaches like meditation to help my symptoms” does not require follow-up teaching. It shows that the client is open to using non-pharmacological methods to manage their symptoms, which can be a beneficial part of a comprehensive treatment plan.

Choice E rationale

The statement “I am at high risk for post-traumatic stress disorder because I have acute stress disorder” does not require follow-up teaching. It’s accurate that individuals with acute stress disorder are at a higher risk of developing post-traumatic stress disorder.

Choice F rationale

The statement “I can learn to manage my thoughts better through therapy” does not require follow-up teaching. It shows that the client understands the benefits of therapy in managing their condition.

A. Nitroglycerin. B. Aspirin. C. Morphine. D. Heparin.

Correct Answer is A

Explanation

Choice A rationale

Nitroglycerin is a medication that is commonly used to treat chest pain or angina. However, it is contraindicated in patients who have taken sildenafil (Viagra) within the last 24 hours due to the risk of severe hypotension, or low blood pressure. Sildenafil is a type of medication known as a phosphodiesterase-5 (PDE5) inhibitor, which works by relaxing the muscles in the walls of blood vessels. Nitroglycerin also works by relaxing blood vessels, so the combination of these two medications can cause a dangerous drop in blood pressure.

Choice B rationale

Aspirin is not typically withheld in patients experiencing chest pain. It is often given to patients who are suspected of having a heart attack because it works by preventing blood clots from forming and blocking the blood vessels of the heart.

Choice C rationale

Morphine is often administered to patients experiencing severe chest pain to help relieve the pain and reduce the workload of the heart. It is not typically withheld unless the patient has a known allergy or other contraindication.

Choice D rationale

Heparin is a blood thinner that is often administered to patients who are suspected of having a heart attack to prevent further blood clots from forming. It is not typically withheld unless the patient has a known allergy, other contraindication, or is at high risk of bleeding.

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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

Which client statements require follow-up teaching by the nurse? Select all that apply.

Correct Answer is ["A","C"]

Explanation

A patient arrives at the emergency department experiencing chest pain after taking sildenafil.Based on the patient’s history, which medication should the nurse withhold?

Correct Answer is A

Explanation

Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

After receiving a change of shift report for patients on a medical-surgical unit, which task should the nurse delegate to an unlicensed assistive personnel (UAP)?

On the first day at 1830, certain medical procedures were initiated for the patient.Which of the following procedures were likely to have been initiated based on the patient’s condition?

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased.The family wishes to see the body before it is taken to the funeral home.Which interventions should the nurse take to prepare the body before the family enters the room? Select all that apply.

An older adult client informs the nurse of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). What action should the nurse take?

While taking vital signs, a critically ill male client grabs the nurse’s hand and asks the nurse not to leave.What is the most appropriate action for the nurse to take?

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?