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.
  • 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.

A. Treatment is to continue for 7 days: This aspect of the prescription is clear and does not require clarification.
B. The appearance of the area is to be documented: Documenting the appearance of the area is a standard nursing practice and does not require clarification from the physician.
C. The procedure is performed with clean technique: The use of clean technique for the procedure is appropriate for the management of a pressure injury and does not require clarification.
D. Room temperature normal saline is prescribed: This aspect of the prescription may require clarification as the nurse needs to ensure that the prescribed solution matches the intended
treatment. Clarification may be necessary if there are specific preferences or considerations regarding the type or temperature of the saline solution to be used.