When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Low intermittent suction prescribed for the nasogastric tube is turned off.

A Hemovac drain is partially full of serous drainage and is not compressed.

The urinary catheter drainage bag is almost completely full of amber urine.

Oxygen is being administered via nasal cannula at 4 L/minute without humidification.

Answer and Explanation

The Correct Answer is D

A. This requires prompt attention but is not immediately life-threatening.

B.   This requires attention but does not pose an immediate threat to the client's condition.

C.   An almost completely full urinary catheter drainage bag requires attention but does not pose an immediate threat to the client's condition.
D.   Administering oxygen without humidification could lead to mucosal dryness and damage, and should be addressed promptly.

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Correct Answer is A

Explanation

A. The priority is to immediately intervene in the care being provided by the UAP and assess the client's condition to ensure prompt intervention if necessary.

B. While educating the UAP is important, immediate assessment and intervention for the client take precedence.
C. Investigating the reason for the UAP's actions can wait until after the client's condition has been assessed and stabilized.
D. Administering oral medications can wait until after the client's condition has been assessed and stabilized.

A. Institute contact precautions for staff and visitors. B. Explain the purpose of a low bacteria diet. C. Monitor the client's white blood cell count. D. Send wound drainage for culture and sensitivity. E. Use standard precautions and wear a mask.

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

Explanation

A. Contact precautions are essential to prevent the spread of MRSA to other patients and healthcare workers. This includes wearing gloves and gowns when entering the patient's room.

B. A low bacteria diet is not specifically relevant to managing MRSA and is more applicable to neutropenic patients.
C. Monitoring the white blood cell count helps in assessing the client's response to infection and identifying any potential systemic involvement.
D. Sending wound drainage for culture and sensitivity is crucial for identifying the specific strain of MRSA and determining the most effective antibiotic treatment.
E. Standard precautions are always necessary, but a mask is not required unless there is a risk of splashing or the patient has a respiratory infection.

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When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

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Correct Answer is A

Explanation

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). What nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

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

Explanation

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