A charge nurse is teaching a group of unit nurses about the policy for clients who have a history of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following information should the nurse include?

A client who has a history of MRSA will need antibiotics.

A client who has a history of MRSA can develop immunity to the infection.

A client who has a history of MRSA requires a protective environment.

A client who has a history of MRSA can still transmit the infection.

Answer and Explanation

The Correct Answer is D

A.   Not all clients with a history of MRSA will require antibiotics. Treatment depends on the presence of active infection, colonization, and other clinical factors.
B.   There is no evidence to suggest that individuals can develop immunity to MRSA. MRSA remains a significant pathogen, and individuals with a history of MRSA remain susceptible to reinfection or colonization.
C.   A protective environment is not typically required for clients with a history of MRSA. Standard precautions, including hand hygiene and appropriate use of personal protective equipment, are sufficient to prevent transmission.

D.   Clients with a history of MRSA can still carry the bacteria on their skin or in their nasal passages and may transmit the infection to others, especially in healthcare settings. Therefore, it is important to adhere to infection control practices to prevent transmission.

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Correct Answer is A

Explanation

A. Providing a flexible activity schedule allows the client to engage in activities that match their energy level and interests, promoting a sense of control and reducing agitation during acute

mania.

B. High-calorie nutritional supplements are not typically indicated solely based on the diagnosis of acute mania. Nutritional needs should be assessed, but providing high-calorie supplements

may not address the underlying issues associated with mania.

C. Allowing the client to eat meals alone in her room may not be safe or therapeutic during acute mania, as supervision during meals can ensure adequate nutrition and prevent potential harm or

inappropriate behaviors.

D. While promoting independence is important, allowing the client to choose her clothes independently may not be appropriate during acute mania, as it could result in wearing

inappropriate attire or exacerbate impulsivity.

A. Monitoring the insertion site for infection B. Checking for orthostatic hypotension C. Forcing fluids D. Immobilizing the affected extremity E. None F. None

Correct Answer is D

Explanation

A. Monitoring the insertion site for infection:
Monitoring for infection is important in the long-term care of a client following cardiac catheterization, but it is not the immediate priority. Infection typically develops over time, not in the immediate postprocedure period.

B. Checking for orthostatic hypotension:
Orthostatic hypotension is not typically associated with cardiac catheterization. Instead, hypotension following the procedure would likely result from bleeding or hypovolemia. Monitoring for vital sign changes is important but not specific to orthostatic hypotension in this context.

C. Forcing fluids:
Encouraging fluids is necessary after cardiac catheterization to help flush out contrast dye and prevent nephropathy. However, this action is not the immediate priority compared to managing the risk of bleeding and maintaining hemostasis at the insertion site.

D. Immobilizing the affected extremity:
Immobilizing the extremity used for catheter insertion (usually the femoral artery) is the immediate priority. This action prevents complications such as bleeding, hematoma formation, or disruption of the arterial puncture site. Maintaining hemostasis and ensuring the integrity of the insertion site are critical during the immediate postprocedure period.

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A charge nurse is teaching a group of unit nurses about the policy for clients who have a history of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following information should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A client has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action?

Correct Answer is D

Explanation

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