A 57-year old female client is admitted to the hospital with left upper arm open wound infection (methicillin-resistant Staphylococcus aureus (MRSA]) and cellulitis.
Indicate whether the nursing actions listed below are Indicated (appropriate or necessary). Contraindicated (could be harmful), or Non-essential (make no difference or are not necessary) for the client's care at this time.
Place the client on Contact Precautions.
Apply cold compress on her left upper arm.
Elevate the client's arm on a pillow.
Take a wound culture every shift to determine if the infection is improving.
Have RN initiate IV access for the client to receive fluids and antibiotic therapy.
Administer subcutaneous sodium heparin every 12 hours.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"C"}}
A. Placing the client on Contact Precautions is appropriate to prevent the transmission of MRSA to other patients and healthcare workers.
B. Applying a cold compress may worsen tissue damage and compromise blood flow, which can exacerbate the wound infection and cellulitis.
C. Elevating the client's arm can help reduce swelling and improve circulation, aiding in the resolution of cellulitis.
D. Taking a wound culture every shift is not necessary or useful, as it can be painful for the client and does not provide timely information on the infection status. A wound culture is usually done once before starting antibiotic therapy and then repeated only if there is no improvement or signs of worsening.
E. Initiating IV access for fluid and antibiotic therapy is necessary for treating the systemic infection caused by MRSA and cellulitis.
F. Subcutaneous sodium heparin is an anticoagulant that prevents blood clots, but it is not indicated for this client unless they have a history or risk of thromboembolic events, such as deep vein thrombosis or pulmonary embolism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
To answer this question, we need to use the formula:
Dose ordered / Dose available = Number of tablets
In this case, the dose ordered is 3 mg and the dose available is 1.5 mg. So we plug in the values and get:
3 mg / 1.5 mg = 2 tablets
Therefore, the nurse should administer 2 tablets of dexamethasone 1.5 mg to give a total of 3 mg.
Correct Answer is D
Explanation
A. While generalized malaise can occur with inflammatory conditions, it is not a hallmark symptom of ankylosing spondylitis.
B. Ankylosing spondylitis primarily affects the spine and sacroiliac joints, not typically the ankles.
C. Deformities of fingers and toes are not characteristic of ankylosing spondylitis; they are more commonly associated with conditions like rheumatoid arthritis.
D. Ankylosing spondylitis is characterized by progressive stiffness and fusion of the spine, leading to decreased mobility and flexibility, especially in the lower back.
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