While caring for a client after a small bowel resection, the nurse is informed that the client has a history of methicillin-resistant Staphylococcus aureus (MRSA). To reduce the risk of recurrence of the MRSA in the postoperative wound, which intervention is most important for the nurse to implement?

Report any increase in the white blood cell count.

Instruct the family to adhere to contact precautions.

Change the surgical dressing readily when soiled.

Wear a face mask while performing wound care.

Answer and Explanation

The Correct Answer is B

MRSA is a highly contagious bacteria that can easily spread from person to person through direct contact or contact with contaminated surfaces. By instructing the family to adhere to contact precautions, the nurse can help prevent the spread of MRSA to the client's postoperative wound. Contact precautions typically involve wearing gloves and a gown when in direct contact with the client or the client's immediate environment.

While reporting any increase in the white blood cell count, changing the surgical dressing when soiled, and wearing a face mask during wound care are all important aspects of postoperative care, they are not specifically targeted at preventing the recurrence of MRSA. Adhering to contact precautions is the most effective measure to prevent the spread of MRSA and protect the client from further infection.

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Correct Answer is A

Explanation

Tertiary prevention programs focus on minimizing the impact of an existing disease or condition and preventing further complications or disability. In the context of cardiovascular disease, one of the goals of tertiary prevention is to provide prompt rehabilitation for clients who have incurred disease complications.

By ensuring that clients who experience complications promptly receive rehabilitation services, the program is effectively addressing the needs of these clients and providing appropriate interventions to minimize the long-term impact of the disease. This outcome indicates that the program is successful in providing the necessary care and support to clients with cardiovascular disease.

Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign focuses on primary prevention rather than tertiary prevention.

At-risk clients receiving an increased number of routine health screenings may be an indicator of improved secondary prevention efforts, but it does not specifically measure the effectiveness of the tertiary prevention program for clients with cardiovascular disease.

Clients reporting new confidence in making healthy food choices is a positive outcome but does not directly reflect the effectiveness of the tertiary prevention program for cardiovascular disease.

A. Wear protective goggles while performing the procedure. B. Apply a water soluble lubricant to the catheter. C. Instill 3 mL of normal saline before suctioning. D. Instruct the client to cough as the suction tip is removed.

Correct Answer is A

Explanation

Wearing protective goggles is important during suctioning to protect the nurse's eyes from potential splashes or aerosolized secretions. Suctioning can generate forceful coughing, gagging, or sneezing in the client, which may cause secretions or mucus to be expelled forcefully and potentially come into contact with the nurse's eyes. Wearing goggles helps prevent eye exposure and reduces the risk of infection transmission.

Applying a water-soluble lubricant to the catheter may be necessary to facilitate the insertion of the suction catheter into the tracheostomy tube, but it is not the most crucial action to include when performing suctioning.

Instilling normal saline before suctioning is not recommended as it can cause potential harm to the client's airway. Instilling saline can lead to bronchospasm, mucosal damage, and other complications. Suctioning should only be performed when necessary to remove secretions and maintain a patent airway.

Instructing the client to cough as the suction tip is removed is not necessary or recommended. Coughing during the suctioning process can be uncontrolled and may increase the risk of trauma to the airway. The nurse should instead provide supportive care and reassurance to the client throughout the procedure.

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Naxlex Comprehensive Predictor Exams

The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicates the program is effective?

Correct Answer is A

Explanation

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Correct Answer is A

Explanation

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.)

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider?

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing severe side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.)