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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.

A.

Place the client in a private room.

B.

Administer intravenous vancomycin

C.

Wear a cover gown when caring for the client.

D.

Restrict fluid intake.

E.

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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Related Questions

Correct Answer is D

Explanation

A. Antibiotic dosages below the minimum concentration are prescribed: This statement is inaccurate. MRSA infections typically require higher than normal doses of antibiotics due to their resistance. Prescribing below the minimum concentration would likely be ineffective.
B. Broad-spectrum antibiotics are used whenever possible: While broad-spectrum antibiotics may cover a wide range of bacteria, they are not always the best choice for treating MRSA.
Targeted antibiotics effective against MRSA are preferred to minimize the risk of further antibiotic resistance.
C. Antibiotics are prescribed only when a viral infection is present: MRSA is a bacterial infection, not viral. Antibiotics are indicated for bacterial infections like MRSA but not for viral infections.
D. Infections become resistant to high doses of antibiotics: This statement is accurate. MRSA is resistant to many common antibiotics, and overuse or inappropriate use of antibiotics can contribute to the development of antibiotic-resistant strains. High doses of antibiotics may not be effective against MRSA, as the bacteria have developed mechanisms to resist their action.

Correct Answer is C

Explanation

A. Exudate: Exudate refers to the fluid, such as pus or serum, that is discharged from a wound.
While exudate may be present in infected wounds, it is not a systemic response.
B. Pain: Pain is a localized response to tissue injury and may be present in infected wounds, but it is not a systemic response.
C. Hyperthermia: Hyperthermia, or an elevated body temperature (fever), is a common systemic response to infection, including wound infections. It indicates the body's immune response to the infection.
D. Hardening of the tissue: Hardening of the tissue, known as induration, may occur in infected wounds due to inflammation but is not a specific systemic response.

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