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 B

Explanation

A. Contact transmission involves direct or indirect contact with infected individuals or contaminated surfaces.
B. Lyme disease is transmitted to humans through the bite of infected ticks, making it a vectorborne disease.
C. Vehicle transmission involves non-living carriers, such as food, water, or inanimate objects, transmitting the infectious agent.
D. Droplet transmission involves respiratory droplets expelled by an infected individual during coughing, sneezing, or talking. Lyme disease is not transmitted through respiratory secretions.

A. urinary tract infection in a client who is sedentary B. vaginal canal infection in a postmenopausal woman C. respiratory infection contracted from a visitor D. wound infection caused by unwashed hands of a caregiver

Correct Answer is D

Explanation

A. A urinary tract infection in a sedentary client does not inherently suggest a hospital-acquired infection.
B. A vaginal canal infection in a postmenopausal woman does not inherently suggest a hospital-acquired infection.
C. A respiratory infection contracted from a visitor does not inherently suggest a hospital-acquired infection.
D. A wound infection caused by unwashed hands of a caregiver suggests a hospital- acquired infection due to the potential for contamination within the healthcare setting.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who reports they are an avid outdoorsman and enjoys hiking, camping, and backpacking, has been admitted for Lyme's Disease. Lyme's Disease is spread by a tick. What is the mode of transmission?

Correct Answer is B

Explanation

A nurse is assigned to the following four clients with infections. The nurse realizes that which client has acquired a hospital-acquired infection?

Correct Answer is D

Explanation

A client had a right knee replaced 4 days ago. The client returns with an elevated temperature for the past 24 hours. Which assessment would the nurse prioritize?

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?

A nurse is completing a head-to-toe assessment on a client who is 3 days post-operative from a right mastectomy. Which of the following should the nurse recognize as a sign of possible infection? Select all that apply.

A client asks the nurse what is meant by the term benign. Which response by the nurse is best?

Tumor staging includes the TNM classification system. The N in TNM would give the physician information on which part of the tumor classification?

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include?

The nurse is caring for several clients on a hospital's surgical unit. Which of the following clients are at greatest risk for developing an infection?

A nurse is attending a continuing education course about communicable diseases. During which phase does the client develop non-specific symptoms such as malaise, fever, and body aches?