A client is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA). Which interventions should the nurse include in the plan of care (POC)? (Select all that apply)

Choice A reason: Applying home oxygen addresses hypoxia but not lethargy and unresponsiveness, which suggest uremic encephalopathy or electrolyte imbalance from missed dialysis. Emergency evaluation is critical, as oxygen does not correct metabolic toxins, making this instruction less urgent than ED transfer.

Choice B reason: Taking the client to the ED is critical, as lethargy and unresponsiveness post-missed dialysis indicate uremia or hyperkalemia, life-threatening CKD complications. Immediate dialysis or medical intervention corrects metabolic imbalances, preventing coma or arrhythmias, making this the most important instruction.

Choice C reason: Avoiding salt intake prevents fluid retention but does not address acute lethargy and unresponsiveness, signs of uremic toxicity. Emergency treatment is needed to correct metabolic derangements, and dietary changes are secondary, making this instruction irrelevant for the immediate crisis.

Choice D reason: Checking thrill and bruit assesses dialysis access patency but does not address lethargy and unresponsiveness, indicating systemic toxicity. ED evaluation and dialysis are urgent, as access function is secondary to treating life-threatening uremia, making this instruction less critical.

Choice A reason: Determining the quickest onset is important but secondary to matching pain severity with dosing. Pain scale rating guides appropriate medication selection, as prescriptions are dosed for specific pain levels, ensuring effective relief without overuse, making this action less critical initially.

Choice B reason: Asking the client to choose medication is inappropriate, as patients lack expertise to select based on pharmacology. Pain scale rating informs the nurse’s decision, aligning with prescribed doses, ensuring safe and effective analgesia, making this action incorrect for professional nursing practice.

Choice C reason: Documenting pain is necessary but not the first action. Comparing pain scale rating with dosing ensures appropriate medication selection, addressing pain effectively before recording. Documentation follows intervention, making this action secondary to selecting the correct analgesic based on severity.

Choice D reason: Comparing pain scale rating with prescribed dosing is critical, as PRN analgesics are dosed for specific pain levels (e.g., mild vs. severe). This ensures the nurse selects the appropriate medication, optimizing pain relief while minimizing overdose risk, making it the priority action before administration.