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 D
Explanation
A) Incorrect- While the history of vomiting is important to assess, it may not be the most crucial information to gather at this point, as the client is postoperative and the focus is on immediate postoperative care.
B) Incorrect- While assessing for fluid intake is important, the client's refusal of ice chips is not an urgent concern compared to other potential complications, such as pain management, oxygenation, and fluid balance.
C) Incorrect- These assessments are important, but the client's history of right hemicolectomy and the current infusion and medication administration require closer attention to fluid balance, pain control, and oxygenation.
D) Correct- While all options are important to consider, the most critical information in this scenario is assessing peripheral pulses and the range of motion of both legs. A right hemicolectomy involves abdominal surgery and decreased or absent peripheral pulses along with a limited range of motion could indicate impaired circulation, thrombosis, or other post-operative complications. These findings might necessitate prompt intervention to prevent potential complications.
Correct Answer is D
Explanation
This is the group of children that the PN should screen for scoliosis because they are at the highest risk of developing this condition. Scoliosis is a lateral curvature of the spine that usually occurs during the growth spurt before puberty. Girls are more likely than boys to have scoliosis, and the condition tends to worsen during adolescence.
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