The nurse is reassessing a 57-year-old female client who was admitted to the hospital with a left upper arm open wound infection (methicillin-resistant Staphylococcus aureus [MRSA] and several gram-negative bacteria) and cellulitis 5 days ago.
Tomorrow she is scheduled for discharge to home with her daughter to continue oral antibiotic therapy for another 10 days.
For each assessment finding, use the choices from the drop-down box to indicate whether the interventions were Effective (helped to meet expected outcomes), Ineffective (did not help to meet expected outcomes), or Unrelated (not related to the expected outcomes).
Client reports mild pain in upper left arm at 2/10 on a scale of 0 to 10.
Client’s early morning finger stick blood glucose (FSBG) was 97 mg/dL (5.4 mmol/L).
Client’s left upper arm slightly reddened when compared with right upper arm.
Client reports that her back is more achy since she came to the hospital.
The Correct Answer is A
Choice A rationale
The client reports mild pain in the upper left arm at 2/10 on a scale of 0 to 10. This indicates that the interventions were effective in managing the pain associated with the infection and cellulitis.
Choice B rationale
The client’s early morning finger stick blood glucose (FSBG) was 97 mg/dL (5.4 mmol/L). This is within the normal range, indicating that the interventions were effective in maintaining the client’s blood glucose levels within the normal range.
Choice C rationale
The client’s left upper arm is slightly reddened when compared with the right upper arm. This could be a sign of inflammation or infection, suggesting that the interventions were ineffective in completely resolving the infection and cellulitis.
Choice D rationale
The client reports that her back is more achy since she came to the hospital. This could be due to a variety of factors, including the hospital bed or a lack of physical activity. It is unrelated to the expected outcomes of the interventions for the infection and cellulitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The client reports mild pain in the upper left arm at 2/10 on a scale of 0 to 10. This indicates that the interventions were effective in managing the pain associated with the infection and cellulitis.
Choice B rationale
The client’s early morning finger stick blood glucose (FSBG) was 97 mg/dL (5.4 mmol/L). This is within the normal range, indicating that the interventions were effective in maintaining the client’s blood glucose levels within the normal range.
Choice C rationale
The client’s left upper arm is slightly reddened when compared with the right upper arm. This could be a sign of inflammation or infection, suggesting that the interventions were ineffective in completely resolving the infection and cellulitis.
Choice D rationale
The client reports that her back is more achy since she came to the hospital. This could be due to a variety of factors, including the hospital bed or a lack of physical activity. It is unrelated to the expected outcomes of the interventions for the infection and cellulitis.
Correct Answer is A
Explanation
Choice A rationale
The apical pulse is located at the fifth intercostal space at the left midclavicular line.
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