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.

Answer and Explanation

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.

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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.

A. Demonstrate how to administer medication via a feeding tube. B. Confirm that the medication is only administered once daily C. Determine if the medication is compatible with the solution. D. Oﬀer to assist in calculating the rate of ﬂow for the mixture.

Correct Answer is A

Explanation

Demonstrate how to administer medication via a feeding tube.The picture shows that the newly hired PN is about to make a serious error by adding the medication directly to the feeding bag, which can cause clogging, contamination, or inaccurate dosing of the medication. The PN should demonstrate how to administer medication via a feeding tube correctly, which involves stopping the feeding, ﬂushing the tube with water, instilling the medication, ﬂushing again, and resuming the feeding.

The other options are not correct because:

Confirming that the medication is only administered once daily is not relevant or helpful, as it does not address the error or teach the correct technique of administering medication via a feeding tube.Determining if the medication is compatible with the solution is not necessary or appropriate, as the medication should not be mixed with the solution in the first place, but given separately through the feeding tube.
Oﬀering to assist in calculating the rate of ﬂow for the mixture is not relevant or helpful, as there should be no mixture of medication and solution in the feeding bag, but separate administration of each through the feeding tube.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An elderly client is 12-hours postoperative for a hernia repair and suddenly becomes agitated, staggers out into the corridor, and demands to be set free. After assisting the client back to bed and administering pain medication, which intervention is best for the practical nurse (PN) to implement?

Correct Answer is C

Explanation

The practical nurse (PN) is observing a newly hired PN who is preparing to administer a liquid medication via a client's feeding tube system as seen in the picture. What action should the PN take?

Correct Answer is A

Explanation

What action should the nurse take first when a client is inadvertently given an incorrect dose of a medication?

Find patient data below. Exhibits here What actions should the nurse plan for the rest of the shift? Select all that apply.

The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPs need additional information about the turning procedure?

While caring for a client with Guillain-Barre syndrome, which finding should the practical nurse (PN) report to the charge nurse?

Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

A client with chronic kidney disease reports to the nurse of feeling increasingly tired. The client receives injections for epoetin alfa three times a week. Which laboratory value should the nurse review?

An elderly client is 12-hours postoperative for a hernia repair and suddenly becomes agitated, staggers out into the corridor, and demands to be set free. After assisting the client back to bed and administering pain medication, which intervention is best for the practical nurse (PN) to implement?

A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?" Which action should the practical nurse (PN) implement?