A client who is paraplegic is admitted with a foul smelling drainage from a sacral ulcer. The client is suspected to have a methicillin resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Use standard precautions and wear a mask.

Institute contact precautions for staff and visitors.

Send wound drainage for culture and sensitivity.

Explain the purpose of a low bacteria diet.

Monitor the client's white blood cell count.

Answer and Explanation

Correct Answer : B,C,E

A. Use standard precautions and wear a mask.

While standard precautions should always be followed to prevent the spread of infection, wearing a mask is not specifically indicated for MRSA unless there is a risk of respiratory transmission. Contact precautions are more appropriate for MRSA.

B. Institute contact precautions for staff and visitors.

Contact precautions are necessary to prevent the spread of MRSA, a highly contagious bacteria. This involves using gloves and gowns when entering the client's room to prevent transmission of the bacteria to others.

C. Send wound drainage for culture and sensitivity.

Culturing the wound drainage helps identify the specific bacteria causing the infection and determines the most effective antibiotics for treatment (sensitivity testing).

D. Explain the purpose of a low bacteria diet.

A low bacteria diet is not typically indicated for managing MRSA infections. Instead, the focus should be on wound care, antibiotic therapy, and infection control measures to address the MRSA infection.

E. Monitor the client's white blood cell count.

Monitoring the white blood cell count helps assess the client's immune response and the severity of the infection. Elevated white blood cell counts may indicate an active infection and the need for further intervention.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Speak loudly and face the client:

While it's important for the nurse to speak clearly and ensure the client can see their face, speaking loudly may be perceived as patronizing or disrespectful. Many older adults may have normal hearing but prefer clear and normal volume speech.

B. Provide a very well-lit meeting space:

Ensuring adequate lighting is important for facilitating communication, especially for older adults who may have visual impairments. However, it is not as crucial as using understandable language.

C. Use everyday language when explaining issues:

This is the most important action. Using everyday language, free of medical jargon, ensures that the information is easily understood by older adult clients. Complex medical terms and terminology may be confusing or overwhelming for them, so using plain language enhances comprehension and promotes effective learning.

D. Underline key words on the written information:

This can be a helpful strategy for emphasizing important points in written materials, but it is not as critical as using everyday language when explaining concepts orally. Additionally, not all older adults may benefit from written information, as some may have visual impairments or difficulties reading. Therefore, oral communication in understandable language is paramount.

A. Administer PRN oral pain medication. B. Review the pain medications prescribed. C. Ask the client what is causing the grimacing. D. Monitor the client's nonverbal behavior.

Correct Answer is C

Explanation

A. Administer PRN oral pain medication:

Administering pain medication without further assessment may not be appropriate, as the client's pain needs must be fully evaluated before intervening with medication. Additionally, pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

B. Review the pain medications prescribed:

While it's important to review the client's pain medications, particularly if the client is exhibiting signs of uncontrolled pain, this intervention should be secondary to further assessment of the client's current pain status.

C. Ask the client what is causing the grimacing:

Asking the client directly about the cause of their grimacing can help clarify their discomfort and provide insight into whether their pain response is being underreported. This approach helps bridge the gap between nonverbal cues and verbal reports.

D. Monitor the client's nonverbal behavior:

While monitoring nonverbal behavior is important, it does not directly address the discrepancy between the client’s grimacing and their verbal denial of pain. This action should be complemented by further assessment to understand the cause of the nonverbal signs.

E. Establish a regular time for going to bed and getting up: This intervention is not relevant to the current situation, as the client is experiencing discomfort while moving.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client who is paraplegic is admitted with a foul smelling drainage from a sacral ulcer. The client is suspected to have a methicillin resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

Correct Answer is C

Explanation

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

The healthcare provider prescribes a 24 hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

A client who is paraplegic is admitted with a foul smelling drainage from a sacral ulcer. The client is suspected to have a methicillin resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which Intervention is most important for the nurse to implement before leaving the client alone?

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.