An older adult client who had a colon resection 8 days ago is straining at stool. The practical nurse (PN) observes sudden spillage of serosanguinous drainage from the client's wound followed by appearance of bowel on the skin. Which complication has occurred?

A. Monitoring daily sodium intake is important for managing AKI, but it is not the immediate priority when addressing acute changes in heart rate and blood pressure.
B. Recording usual eating patterns is not relevant to the immediate concern of elevated heart rate and blood pressure in the context of AKI.
C. Documenting abdominal girth is relevant for assessing fluid status and potential complications like ascites, but it is not the first priority for addressing the acute symptoms of elevated heart rate and blood pressure.
D. Measuring and documenting urinary output is the most critical intervention because it provides essential information on kidney function and fluid balance, which directly impacts heart rate and blood pressure management in AKI.

A. Use a client-specific stethoscope.
Indicated: Using a client-specific stethoscope helps prevent the spread of MRSA between patients. Each client should have dedicated equipment to reduce cross-contamination.
B. Wipe the medication cart with bleach after bringing it into the room.
Not Indicated: While disinfection of surfaces is important, the cart should be cleaned according to hospital protocol, which may involve different cleaning agents. Bleach is not typically used for medication carts and might not be the standard protocol.
C. Measure the client's temperature with a disposable thermometer.
Indicated: Using a disposable thermometer or single-use covers for thermometers prevents the transmission of MRSA to other patients. This practice helps maintain infection control.
D. Change gloves between different clients.
Indicated: Gloves should be changed between patients to prevent the spread of MRSA. This is a standard infection control practice to avoid cross-contamination.
E. Pad the client's side rails with clean linens.
Not Indicated: While padding the side rails may be done for client comfort or safety, it does not specifically address the control of MRSA spread and is not a direct infection control measure for MRSA.