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.
Correct Answer : A,C,D,E
Choice A reason: Standard precautions, including the use of masks, are essential to prevent the spread of MRSA, which can be transmitted through respiratory droplets.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.3"]
Explanation
Step 1: Convert the client's weight from lbs to kg using the conversion factor you provided (1 kg = 2.2 lbs).
So, 110 lbs × (1 kg ÷ 2.2 lbs) = 50 kg
Step 2: Calculate the daily dosage of dalteparin in units using the prescription (150 units/kg).
So, 50 kg × 150 units/kg = 7500 units
Step 3: Determine how many mL of the medication this dosage corresponds to using the information on the syringe (7500 units/0.3 mL).
So, 7500 units × (0.3 mL ÷ 7500 units) = 0.3 mL
The nurse should administer 0.3 mL of dalteparin to the client.
Correct Answer is C
Explanation
Choice A reason: Decreased bowel sounds may be associated with cirrhosis due to altered digestion but do not directly correlate with weight gain.
Choice B reason: An increased respiratory rate can be a sign of many conditions, including fluid overload, but it is not a specific indicator of weight gain due to fluid accumulation.
Choice C reason: Increased abdominal girth is a common sign of ascites, which is fluid accumulation in the abdomen often seen in cirrhosis, correlating with the reported weight gain.
Choice D reason: Decreased level of consciousness may indicate hepatic encephalopathy in cirrhosis patients but does not directly correlate with the weight gain described.
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