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 ["1.32"]
Explanation
Step 1 is to convert the patient’s weight from pounds to kilograms. There are approximately 2.2046 pounds in 1 kilogram. So, the patient’s weight in kilograms is 132 lb ÷ 2.2046 = 59.87 kg.
Step 2 is to calculate the total dose of lorazepam the patient should receive. The prescribed dose is 44 mcg/kg. So, the total dose in micrograms is 44 mcg/kg × 59.87 kg = 2634.28 mcg.
Step 3 is to convert the total dose from micrograms to milligrams. There are 1000 micrograms in 1 milligram. So, the total dose in milligrams is 2634.28 mcg ÷ 1000 = 2.63428 mg.
Step 4 is to calculate the volume of lorazepam solution to administer. The concentration of the solution is 2 mg/mL. So, the volume in milliliters is 2.63428 mg ÷ 2 mg/mL = 1.31714 mL. Therefore, the nurse should administer approximately 1.32 mL of the lorazepam solution, rounding to the nearest hundredth as required.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}
Explanation
Based on the provided information, here are the interventions the nurse should perform:
- Check capillary refill on bilateral upper extremities.- Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
- Administer ondansetron 4 mg IV.- Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
- Inspect the bandage for drainage.- Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.
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