Which client assessment should the nurse perform during nasopharyngeal suctioning?

A. Use standard precautions and wear a mask.

While standard precautions should always be followed to prevent the spread of infection, wearing a mask is not specifically indicated for MRSA unless there is a risk of respiratory transmission. Contact precautions are more appropriate for MRSA.

B. Institute contact precautions for staff and visitors.

Contact precautions are necessary to prevent the spread of MRSA, a highly contagious bacteria. This involves using gloves and gowns when entering the client's room to prevent transmission of the bacteria to others.

C. Send wound drainage for culture and sensitivity.

Culturing the wound drainage helps identify the specific bacteria causing the infection and determines the most effective antibiotics for treatment (sensitivity testing).

D. Explain the purpose of a low bacteria diet.

A low bacteria diet is not typically indicated for managing MRSA infections. Instead, the focus should be on wound care, antibiotic therapy, and infection control measures to address the MRSA infection.

E. Monitor the client's white blood cell count.

Monitoring the white blood cell count helps assess the client's immune response and the severity of the infection. Elevated white blood cell counts may indicate an active infection and the need for further intervention.

In this situation, the best approach for the nurse to use when questioning the client about sexual activity is:

A. Ask questions in a vague, nonspecific format.

This approach may lead to confusion or misunderstanding on the part of the client and may not elicit the necessary information about sexual activity. It's important for the questions to be clear and specific to ensure accurate assessment and appropriate care.

B. Get the most difficult questions over with first.

Starting with the most difficult or sensitive questions may put the client on the defensive or make them feel uncomfortable. It's generally more effective to build rapport and trust with the client before broaching sensitive topics.

C. Begin with questions that are less sensitive in nature.

This approach allows the nurse to establish rapport and build trust with the client before addressing more sensitive topics such as sexual activity. Starting with less sensitive questions can help the client feel more comfortable and open up about their concerns.

D. Share personal values to put the client at ease.

Sharing personal values may not be appropriate or helpful in this context, as it could potentially influence the client's responses and compromise the objectivity of the assessment. The focus should be on creating a safe and supportive environment for the client to discuss their health concerns without feeling judged.