A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with a possible methicillin-resistant Staphylococcus aureus (MRSA) infection. What intervention(s) should the nurse include in the plan of care? Select all that apply.

Use standard precautions and wear a mask.

Explain the purpose of a low bacteria diet.

Institute contact precautions for staff and visitors.

Send wound drainage for culture and sensitivity.

Monitor the client's white blood cell count.

Answer and Explanation

Correct Answer : C,D,E

Choice A reason: Standard precautions are always used, but a mask is not specifically required unless performing a procedure that risks splashing. MRSA is primarily spread through direct contact, so masks are not the main precaution for this client.

Choice B reason: A low bacteria diet is not typically required for MRSA or osteomyelitis management and does not directly impact the treatment or prevention of infection spread.

Choice C reason: Contact precautions are critical for preventing MRSA transmission, as it can be spread by direct contact with the infected wound or contaminated surfaces.

Choice D reason: Sending wound drainage for culture and sensitivity is crucial to identify the specific strain of MRSA and determine the most effective antibiotic treatment.

Choice E reason: Monitoring the white blood cell count is important to assess the body's response to infection and the effectiveness of treatment.

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Correct Answer is A

Explanation

Choice A reason: Pouring warm water over the perineal area can stimulate the micturition reflex, which may help the client void. It is a non-invasive, first-line intervention to promote natural voiding in clients with urinary incontinence. The nurse should evaluate its effectiveness as it can be a simple yet effective method to assist the client.

Choice B reason: While recommending a complete bath may help maintain hygiene, it does not directly address the immediate need to stimulate voiding. The nurse's priority is to manage the incontinence issue effectively and a bath can be considered after addressing the client's immediate needs.

Choice C reason: Suggesting catheter insertion may be premature without first attempting less invasive measures. Catheterization carries risks such as infection and should be considered only when other interventions are ineffective or not feasible.

Choice D reason: There is no evidence to suggest that pouring warm water over the perineal area promotes infection in elderly females. In fact, proper perineal care is essential in preventing infections, especially in clients with incontinence.

A. Obtain a clean, voided urine specimen for analysis. B. Evaluate the client's response to bladder training efforts. C. Provide protective undergarments for the client. D. Encourage increased fluid intake for 24 hours.

Correct Answer is A

Explanation

Choice A reason: Obtaining a urine specimen is essential for analyzing possible infections or other abnormalities that could be causing urinary incontinence.

Choice B reason: While evaluating the client's response to bladder training is important, it is not the first step before diagnosing the cause of new-onset incontinence.

Choice C reason: Providing protective undergarments may help manage symptoms but does not address the underlying cause of the incontinence.

Choice D reason: Encouraging increased fluid intake could potentially exacerbate incontinence symptoms and is not a diagnostic intervention.

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A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with a possible methicillin-resistant Staphylococcus aureus (MRSA) infection. What intervention(s) should the nurse include in the plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

Correct Answer is A

Explanation

An older adult client arrives at the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement?

Correct Answer is A

Explanation

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