A nurse is performing an admission assessment for a male client scheduled for the removal of an internal fixation device from a previous ankle fracture. The client informs the nurse that he was recently treated with intravenous vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which of the following actions should the nurse take? (Select all that apply.)

Continue to monitor the client for signs of an infection.

Call the healthcare provider for a prescription for linezolid.

Collect multiple sets of blood cultures for MRSA screening.

Place the client on contact transmission precautions.

Obtaining a sputum specimen for culture and sensitivity

Answer and Explanation

Correct Answer : A,C,D

Choice A reason: This is a correct answer because continuing to monitor the client for signs of an infection is important to detect any recurrence or complication of MRSA infection. MRSA is a type of bacteria that is resistant to many antibiotics and can cause serious skin, soft tissue, bone, joint, or bloodstream infections. The nurse should assess the client's vital signs, wound appearance, pain level, and laboratory results.

Choice B reason: This is not a correct answer because calling the healthcare provider for a prescription for linezolid is not necessary unless the client has an active MRSA infection that requires treatment. Linezolid is an antibiotic that can be used to treat MRSA infections, but it has potential side effects and interactions that need to be considered. The nurse should not prescribe or administer antibiotics without a valid order.

Choice C reason: This is a correct answer because collecting multiple sets of blood cultures for MRSA screening is important to identify any asymptomatic bacteremia or sepsis that could result from MRSA infection. MRSA can enter the bloodstream through wounds, catheters, or surgical sites and cause life-threatening complications such as endocarditis, osteomyelitis, or pneumonia. The nurse should obtain blood samples from different sites and times and send them to the laboratory for analysis.

Choice D reason: This is a correct answer because placing the client on contact transmission precautions is important to prevent the spread of MRSA to other clients, staff, or visitors. Contact transmission precautions include wearing gloves and gowns when entering the client's room, using dedicated or disposable equipment, and performing hand hygiene before and after contact with the client or their environment.

Choice E reason: This is not a correct answer because obtaining a sputum specimen for culture and sensitivity is not relevant to the client's history of MRSA wound infection. Sputum culture and sensitivity is a test that can be used to diagnose respiratory infections caused by bacteria, fungi, or viruses. The nurse should only obtain a sputum specimen if the client has signs or symptoms of a respiratory infection, such as cough, fever, chest pain, or dyspnea.

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Correct Answer is B

Explanation

Choice A reason: Explaining to the client that the dosage has been changed is not a safe action because it may not be true. The nurse should not assume that the prescribed dosage is correct or different from the previous one without verifying it with the healthcare provider or the medication record.

Choice C reason: Informing him that he may refuse the medication and documenting whether or not he takes it is not a responsible action because it does not address the issue of dosage discrepancy. The nurse should respect the client's right to refuse medication, but should also educate him about the benefits and risks of taking or not taking it. The nurse should also try to resolve any barriers or concerns that may affect the client's adherence to medication.

Choice D reason: Telling him to take the medication then verifying the dosage at the next healthcare team meeting is not a timely action because it may cause harm or complications to the client. The nurse should not administer any medication without checking its accuracy and appropriateness for the client. The nurse should also report and document any medication incidents as soon as possible.

A. Provide disposable training pants while calming the mother. B. Refer the mother to a community parent education program. C. Suggest that the mother consult a pediatric nephrologist. D. Inform the mother that toilet training is slower for boys.

Correct Answer is A

Explanation

Choice A reason: This is correct because it addresses both the physical and emotional needs of the child and the mother. The nurse should provide comfort and reassurance to the mother and explain that occasional accidents are normal and not a sign of failure.

Choice B reason: This is incorrect because it implies that the mother is incompetent and needs external help. The nurse should first establish rapport and trust with the mother before suggesting any resources or interventions.

Choice C reason: This is incorrect because it suggests that there is something wrong with the child's kidneys, which may alarm and offend the mother. The nurse should not jump to conclusions without assessing the child's history and symptoms.

Choice D reason: This is incorrect because it generalizes and stereotypes boys as being slower than girls in toilet training. The nurse should not make assumptions based on gender and should respect individual differences.

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Correct Answer is A

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