A nurse is caring for a patient who has undergone a small bowel resection and has a history of methicillin-resistant Staphylococcus aureus (MRSA).
Which nursing intervention is most crucial to minimize the risk of a MRSA recurrence in the postoperative wound?
Change the surgical dressing promptly when it becomes soiled.
Monitor for any increase in the white blood cell count.
Educate the family on the importance of adhering to contact precautions.
Always wear a face mask while performing wound care.
The Correct Answer is A
Choice A rationale
Changing the surgical dressing promptly when it becomes soiled is crucial to minimize the risk of a MRSA recurrence in the postoperative wound. A soiled dressing can become a medium for bacterial growth, including MRSA, and can potentially contaminate the wound.
Choice B rationale
Monitoring for any increase in the white blood cell count is important in detecting an infection, including a MRSA infection. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.
Choice C rationale
Educating the family on the importance of adhering to contact precautions is important in preventing the spread of MRSA. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.
Choice D rationale
Wearing a face mask while performing wound care can help prevent the spread of MRSA. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While monitoring the respiratory rate is important in a patient receiving opioids like hydromorphone, it does not directly indicate whether the patient is receiving an equianalgesic dose of the medication.
Choice B rationale
Pain scale assessment is the most direct way to evaluate if the patient is receiving an equianalgesic dose of hydromorphone. Equianalgesic refers to a dose of one opioid that would provide the same level of pain relief as a given dose of another opioid. If the patient’s pain is well-controlled, it suggests that the dose of hydromorphone is equianalgesic to the dose of the previous opioid.
Choice C rationale
Monitoring blood pressure is important in a patient receiving opioids as these medications can cause hypotension. However, blood pressure does not directly indicate whether the patient is receiving an equianalgesic dose of hydromorphone.
Choice D rationale
While it’s important to monitor the level of consciousness in a patient receiving opioids as these medications can cause sedation, it does not directly indicate whether the patient is receiving an equianalgesic dose of hydromorphone.
Correct Answer is C
Explanation
Choice A rationale
Responding to the code while performing tracheostomy care could potentially put the current patient at risk. The nurse has a responsibility to ensure the safety of the patient they are currently caring for.
Choice B rationale
Closing the room door does not address the immediate needs of either patient and does not contribute to the safety or care of the patients.
Choice C rationale
Calling for an assistant is the most appropriate action. This allows the nurse to ensure the safety of the current patient while also allowing for a response to the code blue. The assistant can continue care for the current patient, or the nurse can delegate the assistant to respond to the code while the nurse continues care for the current patient.
Choice D rationale
Finishing the procedure could delay response to the code blue, potentially putting the other patient at risk.
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