A nurse is caring for a client.

Exhibits

For each potential nursing action, click to specify if the action is essential. nonessential, or contraindicated for the client.

Place the client in a private room.

Administer intravenous vancomycin

Wear a cover gown when caring for the client.

Restrict fluid intake.

Initiate supplemental oxygen.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Place the client in a private room.
- Essential: Placing the client in a private room helps prevent the spread of MRSA to other patients and reduces the risk of transmission.
Administer intravenous vancomycin.
- Essential: Vancomycin is an appropriate antibiotic choice for treating MRSA infections, and administering it intravenously allows for effective delivery of the medication to combat the infection.
Wear a cover gown when caring for the client.
- Essential: Wearing a cover gown provides an additional barrier of protection against potential contact with the client's infected wound and helps prevent transmission of MRSA to healthcare workers and other patients.
Restrict fluid intake.
- Contraindicated: Restricting fluid intake is not indicated in this scenario. Adequate hydration is essential for supporting the body's immune response and maintaining organ function, especially in the presence of fever and infection.
Initiate supplemental oxygen.
- Nonessential: Supplemental oxygen is not indicated based on the client's oxygen saturation of 96% on room air. Oxygen supplementation is typically reserved for clients who are hypoxic or experiencing respiratory distress, which is not the case here.

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Correct Answer is A

Explanation

A. Nonadherent dressing: Nonadherent dressings are suitable for small skin tears in older adult clients because they prevent the dressing from sticking to the wound bed, minimizing trauma during dressing changes.
B. Paste: Paste dressings are typically used for wound packing or for managing exuding wounds, not for small skin tears.
C. Moist, sterile gauze: While moist, sterile gauze can be used for wound dressings, it may adhere to the wound bed, causing further trauma during dressing changes.
D. Duoderm: Duoderm is a type of hydrocolloid dressing used for moderate to heavily exuding wounds, not for small skin tears.

A. Skin lesions are seen as solid predictors of the general health state. B. The patient's psychological health is best predicted by the skin. C. Detection of skin cancer is the only reason to assess the client's skin. D. The skin is a good communicator regarding the client's overall health.

Correct Answer is D

Explanation

A. Skin lesions are seen as solid predictors of the general health state: While skin lesions can provide valuable information about a patient's health, they are not the only indicator. Changes in the skin can indicate various health conditions, not just lesions.
B. The patient's psychological health is best predicted by the skin: While changes in the skin can sometimes be associated with psychological health conditions, they are not the sole predictors. Psychological health is assessed through a comprehensive evaluation, including observation, interview, and assessment tools.
C. Detection of skin cancer is the only reason to assess the client's skin: While skin cancer detection is an important aspect of skin assessment, it is not the only reason. Skin assessment provides valuable information about overall health, hydration status, circulation, and potential systemic conditions.
D. The skin is a good communicator regarding the client's overall health: The skin can provide valuable clues about a patient's overall health status. Changes in skin color, texture, moisture, and integrity can indicate underlying health conditions, nutritional deficiencies, circulation problems, or systemic diseases. Therefore, focusing on any changes noted in the patient's skin is essential for comprehensive assessment and early detection of potential health issues.

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A nurse is caring for a client. Exhibits For each potential nursing action, click to specify if the action is essential. nonessential, or contraindicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following dressing types is most appropriate for the nurses to apply to a small skin tear in an older adult client?

Correct Answer is A

Explanation

The nurse in a healthcare provider's (HCP's) office is reassessing a patient's skin and making a comparison with the information from the patient's last visit. For which reason does the nurse focus on any changes noted in the patient's skin?

Correct Answer is D

Explanation

The nurse has contributed to a staff education program about the principles for the first tier of standard precautions. Which statement by a nursing student indicates a correct understanding of the teaching?

When performing dressing changes in an older client, what should the nurse assess for?

A nurse is assisting with the care of a client with the history below: Exhibits A nurse is caring for the client. Which of the following actions should the nurse take? Select (2) answers that apply.

Which of the following infections would the nurse recognize as being a health care-associated infection?

A nurse is reinforcing teaching with a client about treatment of Methicillin-Resistant Staphylococcus Aureus (MRSA). Which of the following information should the nurse include in the teaching?

A patient has been recently diagnosed with an upper respiratory infection. His brother arrives and would like to visit. The patient says he is not feeling strong enough to have visitors. Which symptom would indicate to the nurse that the client is developing a complication?

A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?

A nurse is caring for a client.

Exhibits

For each potential nursing action, click to specify if the action is essential. nonessential, or contraindicated for the client.