A client states that he has been experiencing oozing from his wound. What is the nurse's priority assessment for this client?
Culture the wound
Apply topical ointment to the wound
Inspect the wound and assess the drainage
Call the provider to initiate antibiotics
The Correct Answer is C
Choice A reason: Culturing the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Culturing the wound is a procedure that involves collecting a sample of the wound drainage and sending it to the laboratory for analysis, which can help identify the type and source of infection. Culturing the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a sterile technique.
Choice B reason: Applying topical ointment to the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Applying topical ointment to the wound is a procedure that involves applying a medication or a dressing to the wound site, which can help prevent or treat infection, inflammation, or pain. Applying topical ointment to the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a clean technique.
Choice C reason: Inspecting the wound and assessing the drainage is the nurse's priority assessment for this client, because it is the most urgent and relevant action. Inspecting the wound and assessing the drainage is a process that involves observing and measuring the wound site and the wound exudate, which can reveal the presence and severity of infection, injury, or healing. Inspecting the wound and assessing the drainage is an essential assessment, as it can guide the diagnosis, treatment, and evaluation of the client's condition.
Choice D reason: Calling the provider to initiate antibiotics is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Calling the provider to initiate antibiotics is a communication that involves reporting the client's situation and requesting a prescription for an antimicrobial agent, which can help fight or prevent infection. Calling the provider to initiate antibiotics is an important communication, but it should be done after inspecting the wound and assessing the drainage, and with the necessary data and documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement is correct and should be included in the nurse's teaching. It informs the client about the availability and benefits of adaptive devices that can enhance their home safety and independence. It also shows the nurse's empathy and respect for the client's needs and preferences.
Choice B reason: This statement is incorrect and should not be included in the nurse's teaching. It reflects the nurse's personal opinion and bias, and it may discourage the client from seeking help or expressing their pain. It also shows the nurse's lack of understanding and compassion for the client's condition and challenges.
Choice C reason: This statement is incorrect and should not be included in the nurse's teaching. It suggests an unsafe and hazardous practice that can increase the risk of falls and injuries for the client. It also shows the nurse's negligence and irresponsibility for the client's home safety.
Choice D reason: This statement is incorrect and should not be included in the nurse's teaching. It implies that the client is noncompliant and blames them for their home safety issues. It also shows the nurse's judgmental and accusatory attitude towards the client.
Correct Answer is A
Explanation
Choice A reason: Wearing a gown is the correct answer, because it is the appropriate PPE for contact precautions, which are required for clients who have MRSA. MRSA is a type of bacteria that is resistant to many antibiotics and can cause serious infections in the skin, blood, lungs, or other organs. MRSA can be transmitted by direct or indirect contact with the infected wound or contaminated surfaces. Wearing a gown can protect the nurse's clothing and skin from exposure to MRSA.
Choice B reason: Wearing sterile gloves is not the correct answer, because it is not the appropriate PPE for contact precautions, which are required for clients who have MRSA. Sterile gloves are used for sterile procedures, such as inserting a catheter or changing a dressing, not for routine assessments, such as checking the pulse. Wearing sterile gloves can be wasteful and unnecessary, and it does not provide adequate protection from MRSA.
Choice C reason: Wearing a PAPR mask is not the correct answer, because it is not the appropriate PPE for contact precautions, which are required for clients who have MRSA. PAPR stands for powered airpurifying respirator, and it is a type of mask that filters the air and provides positive pressure to the wearer. PAPR masks are used for airborne precautions, which are required for clients who have diseases that can be spread through the air, such as tuberculosis or measles, not for clients who have MRSA.
Choice D reason: Wearing a surgical mask is not the correct answer, because it is not the appropriate PPE for contact precautions, which are required for clients who have MRSA. Surgical masks are used for droplet precautions, which are required for clients who have diseases that can be spread through respiratory droplets, such as influenza or pertussis, not for clients who have MRSA.
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