While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?
Reapply a sterile non-adhesive dressing.
Limit visitors to immediate family only.
Administer prescribed antibiotics.
Request a nutrition consult.
The Correct Answer is C
A) Incorrect- reapplying a sterile non-adhesive dressing is not enough to address the infection.
The nurse should also clean the wound, apply topical antimicrobial agents, and change the dressing regularly.
B) Incorrect- limiting visitors to immediate family only is not a sufficient infection control measure. The nurse should also use standard precautions, such as wearing gloves, gowns, masks,
and eye protection, and educate the visitors about hand hygiene and proper disposal of contaminated items.
C) Correct- Administering prescribed antibiotics is the most important action because it can help treat the infection and prevent it from spreading to other parts of the body or to other people. MRSA is resistant to many common antibiotics, so it is essential to follow the prescription and monitor the client's response.
D) Incorrect- requesting a nutrition consult is not a priority action. While nutrition is important for wound healing, it does not directly affect the infection. The nurse should first administer antibiotics and then assess the client's nutritional status and needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client may be experiencing postoperative delirium, which is a transient state of confusion, disorientation, agitation, or hallucinations that can occur after surgery, especially in elderly clients. The PN should raise the side rails and notify the family to come and stay with the client, as this can provide safety, comfort, and reassurance for the client.
The other options are not correct because:
A. Administering a prescribed narcotic antagonist may not be appropriate or necessary, as the client's agitation may not be caused by analgesic accumulation, but by other factors such as hypoxia, infection, electrolyte imbalance, or sensory deprivation.
B. Notifying the healthcare provider and requesting a prescription for restraints may not be the best intervention, as restraints can increase the client's agitation, anxiety, or injury. Restraints should be used only as a last resort when other measures have failed or when there is an imminent risk of harm.
D. Instructing a UAP to keep the upper side rails up and check on the client every 15 minutes may not be sufficient or effective, as the client may still try to get out of bed or become more agitated by being left alone. The PN should involve the family or stay with the client until he or she is calm and oriented.
Correct Answer is ["B","C","D"]
Explanation
Client's pain rating on a scale of 1 to 10: This information helps assess the client's current pain level and determine the need for pain medication.
Time of the last administration of pain medication: This is important to avoid overdosing or administering pain medication too frequently. It helps ensure that pain medication is given at the appropriate time intervals.
Effectiveness of the last pain medication administered: Understanding whether the previous dose provided relief or not helps guide the choice of the next medication or dosage.
The other options are not directly related to the immediate decision of administering pain medication:
Height and weight of the client prior to admission may be part of the client's medical history but are not typically required information just before administering pain medication.
A history of pain medication use during the past year is important information but may be already documented in the client's medical records and not necessary to obtain immediately before administration.
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