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. In this phase, the client develops non-specific symptoms such as malaise, fever, and body aches, indicating the onset of the disease.
B. This phase occurs after the pathogen enters the body but before symptoms appear.
C. This phase is marked by recovery and the resolution of symptoms.
D. This phase refers to the period during which the disease can be transmitted to others.
Correct Answer is B
Explanation
A. Mild exercise like gardening may be suitable for some clients with leukopenia, but it is not a specific precaution related to their immune status.
B. Clients with leukopenia have reduced white blood cell counts, making them more susceptible to infections. Avoiding crowds helps reduce the risk of exposure to infectious agents.
C. Monitoring oral temperature weekly is important for early detection of infection.
However, it should be done more frequently, daily and not weekly.
D. While eating plenty of fresh fruits and vegetables is generally beneficial for overall health, a patient with leukopenia is encouraged to eat cooked foods due to their low immunity.
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