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 A
Explanation
A. The N in the TNM classification system stands for lymph node involvement, providing information on the presence and extent of lymph node involvement by the tumor.
B. The tissue or cell of origin is typically denoted by the primary tumor classification.
C. The amount of differentiation of the cells is usually described separately and not specifically represented by the N in the TNM system.
D. Tumor obstruction is not directly assessed by the N component of the TNM system.
Correct Answer is C
Explanation
A. Platelets are involved in blood clotting and are not directly related to the body's ability to withstand exposure to pathogens.
B. Hemoglobin carries oxygen in the blood and is not directly related to the body's immune response to pathogens.
C. Neutrophils are a type of white blood cell that plays a key role in the body's immune response to pathogens, including phagocytosis.
D. Erythrocytes, or red blood cells, carry oxygen in the blood and are not directly involved in the body's immune response to pathogens.
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