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)

Place the client in contact precautions

Administer vancomycin as prescribed

Obtain a wound culture

Monitor white blood cell count

Ensure hand hygiene compliance

Answer and Explanation

Correct Answer : A,B,C,D,E

Choice A reason: Contact precautions prevent MRSA spread, as it transmits via direct contact or contaminated surfaces. Isolation with gowns and gloves reduces nosocomial infection risk, critical for protecting staff and patients, making this a key intervention in the plan of care for suspected MRSA.

Choice B reason: Administering vancomycin is essential, as it treats MRSA, a resistant bacterium requiring specific antibiotics. Vancomycin targets cell wall synthesis, effective against MRSA, and prompt administration prevents systemic spread, making it a critical intervention for confirmed or suspected infections.

Choice C reason: Obtaining a wound culture confirms MRSA diagnosis by identifying the pathogen and its antibiotic sensitivity. This guides targeted therapy, ensuring effective treatment and preventing resistance, making it a vital step in managing suspected MRSA infections in the care plan.

Choice D reason: Monitoring white blood cell count tracks infection severity, as leukocytosis indicates MRSA’s systemic inflammatory response. This helps assess treatment response and complications, making it an important intervention to evaluate the client’s condition and guide ongoing management of the infection.

Choice E reason: Ensuring hand hygiene compliance prevents MRSA transmission, a highly contagious pathogen spread via contact. Rigorous handwashing reduces cross-contamination, protecting the client, staff, and others, making it an essential intervention in the care plan for infection control.

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Correct Answer is B

Explanation

Choice A reason: Evaluating consciousness assesses neurological status but is less urgent than cardiac monitoring. Electrical injuries risk arrhythmias due to current disrupting cardiac conduction, and altered consciousness is secondary. Monitoring heart rhythm prevents sudden death, making this intervention less critical initially.

Choice B reason: Continuous cardiac monitoring is critical, as electrical injuries can cause arrhythmias like ventricular fibrillation by disrupting cardiac ion channels. Current through the body (hand to foot) risks heart involvement, and monitoring detects life-threatening rhythms, making it the priority intervention for immediate safety.

Choice C reason: Passive range of motion prevents contractures but is not urgent post-electrical injury. Cardiac arrhythmias are a primary risk, as current affects heart conduction, and mobility is secondary. Monitoring heart rhythm prevents acute complications, making this intervention less immediate.

Choice D reason: Assessing burn depth and extent guides wound care but is secondary to cardiac risks. Electrical injuries cause internal damage, particularly arrhythmias, and cardiac monitoring prevents sudden death, making burn assessment less urgent than ensuring cardiac stability in the initial plan.

A. Measure the client’s intake and output B. Increase the flow of the bladder irrigation C. Provide additional oral fluid intake D. Administer a PRN dose of an antispasmodic agent

Correct Answer is B

Explanation

Choice A reason: Measuring intake and output monitors fluid balance but does not address blood clots obstructing TURP drainage. Clots risk bladder distension or hemorrhage, and increasing irrigation flow directly clears the tubing, making this action secondary to preventing immediate complications in post-prostate surgery.

Choice B reason: Increasing bladder irrigation flow is the best initial action, as blood clots in TURP drainage indicate clot formation, risking obstruction. Faster irrigation flushes clots, preventing bladder distension or bleeding, maintaining catheter patency, and ensuring postoperative stability, making it the priority intervention.

Choice C reason: Providing oral fluids increases urine output but does not directly clear blood clots in TURP drainage. Clots require irrigation adjustment to prevent obstruction, and oral hydration is secondary, as it does not address the immediate risk of catheter blockage or bladder complications.

Choice D reason: Administering an antispasmodic addresses bladder spasms but not blood clots in TURP drainage. Clots cause obstruction, not spasms, and increasing irrigation flow directly resolves the issue, making antispasmodics irrelevant for the immediate problem of maintaining catheter patency.

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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)

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Naxlex Comprehensive Predictor Exams

A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client’s plan of care (POC)?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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