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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. It is possible for an infection to be present without an elevated temperature, especially in older adults.
B. While some symptoms may be common in older adults, the presence of symptoms alone does not exclude the possibility of infection.
C. The resolution of infection cannot be determined solely based on the absence of fever.
D. Older adults may have a blunted fever response to infection, leading to a lack of fever despite the presence of other symptoms.

A. Prevent introduction of different organisms into the wound B. Decrease swelling in wound area from accumulation of organisms C. Decrease the pain caused by organisms that may have collected D. Render area sterile

Correct Answer is A

Explanation

A. Cleaning the wound from the inner to outer area helps prevent introducing microorganisms from the surrounding skin into the wound, reducing the risk of infection.
B. While preventing infection may indirectly reduce swelling associated with inflammation, the primary rationale for cleansing the wound in this manner is to minimize the introduction of microorganisms.

C. Pain reduction is not the primary goal of cleaning the wound from the inner to outer area, although minimizing the risk of infection may help prevent secondary pain caused by infection.
D. While maintaining a clean environment is essential for wound care, the goal of cleansing the wound in this manner is to reduce the risk of introducing microorganisms, not to achieve sterility.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is caring for a client with a large abdominal wound. The nurse knows to cleanse the wound from the inner to outer area. What is the rationale for cleaning the wound in this manner?

Correct Answer is A

Explanation

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