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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While gall bladder surgery carries a risk of infection, having osteoarthritis does not significantly increase the risk compared to other factors listed.
B. Plastic surgery and being overweight may increase the risk of surgical site infections, but age and comorbidities are more significant factors.
C. A fractured wrist may increase the risk of infection at the fracture site, but it is not as significant a risk factor as advanced age and comorbidities.
D. Advanced age, rheumatoid arthritis, foot surgery, and Foley catheter insertion are all factors that increase the risk of infection, making this client the most vulnerable.
Correct Answer is ["8"]
Explanation
To answer this question, the nurse needs to use the formula:
mL = (mg x 1 mL) / mg
where mg is the prescribed dose and mL is the available dose. Plugging in the values, we get:
mL = (80 mg x 1 mL) / 10 mg mL = 8 mL
Therefore, the nurse should administer 8 mL of furosemide oral solution.
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