A 57-year-old female patient was admitted to the hospital with a left upper wound infection (methicillin-resistant Staphylococcus aureus [MRSA] and several gram-negative bacteria) and cellulitis 5 days ago.

Her wound is packed and requires a dressing change twice a day.

She is scheduled for discharge to home with her daughter to continue antibiotic therapy for another week.

What health teaching should the nurse include as part of the discharge instructions for the patient and her daughter?

Select all that apply.

Use a sterile technique when packing the wound and changing the dressing twice a day.

Stop taking the antibiotics when your arm feels better and is not reddened.

Notify your primary health care provider if your diarrhea gets worse.

Avoid strenuous activity and take frequent rest periods.

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale
Using a sterile technique when packing the wound and changing the dressing twice a day is crucial to prevent further infection.
Choice B rationale
It is important to complete the full course of antibiotics, even if symptoms improve, to ensure the infection is fully treated and to prevent antibiotic resistance.
Choice C rationale
Diarrhea can be a side effect of some antibiotics. If it gets worse, it could be a sign of an infection such as Clostridium difficile, which requires immediate medical attention.
Choice D rationale
Rest is important for recovery. Strenuous activity could delay healing and increase the risk of complications.

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Correct Answer is A

Explanation

Choice A rationale
The apical pulse is located at the fifth intercostal space at the left midclavicular line.

A. Does not let patient know that nurse is assessing respirations. B. Auscultating heart sounds using bell of stethoscope. C. Assessing both carotid pulse sites at the same time. D. Cleaning stethoscope between patient assessments.

Correct Answer is C

Explanation

Choice A rationale
It is a common practice for nurses to assess a patient’s respirations without explicitly stating so. This is because patients may alter their breathing pattern if they know it’s being observed.
Choice B rationale
Auscultating heart sounds using the bell of the stethoscope is a standard practice in nursing. The bell of the stethoscope is used specifically to listen to low-frequency sounds such as heart murmurs.
Choice C rationale
Assessing both carotid pulse sites at the same time is dangerous and should be avoided. This action can lead to reduced blood flow to the brain, possibly causing the patient to faint or experience a decrease in cerebral blood flow.
Choice D rationale
Cleaning the stethoscope between patient assessments is a recommended practice to prevent the spread of infections.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the apical pulse. Where should the stethoscope be placed?

Correct Answer is A

Explanation

Which of the following actions by the new nurse requires immediate intervention by the experienced nurse?

Correct Answer is C

Explanation

The nurse is caring for a newly admitted client. Which intervention is the best example of a culturally appropriate nursing intervention?

The nurse reviews morning lab results on his patients. Based on these lab results which patient should the nurse see first?

Which statement accurately describes the relationship between subjective and objective data in documentation?

Prescription Order: 1g in 50 mL to infuse over 30 minutes; gtt factor= 15gtts/1mL. How many drops per minute will you infuse?

The nurse understands that they need to practice in a way that can be explained to the patients and employer. Which of the following terms is this an example of?

A nurse working in a care area that uses paper charting notices an error when recording a patient’s vital signs in the patient record. Which option adheres to The Centers for Medicare & Medicaid Services (CMS) guidelines for making corrections to documentation?

The nurse is caring for a client diagnosed with a systemic staphylococci infection from the client’s own flora. The nurse correctly notes that this is an example of a(n):