An older adult client is admitted from a long-term care facility with purulent exudate draining from a sacral pressure ulcer is suspected to have methicillin-resistant Staphylococcus aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? Select all that apply.

Monitor the client's white blood cell count.

Send wound drainage for culture and sensitivity.

Institute contact precautions for staff and visitors.

Explain the purpose of a low bacteria diet.

Use standard precautions and wear a mask.

Answer and Explanation

Correct Answer : A,B,C

A. Monitor the client's white blood cell count. An elevated white blood cell (WBC) count indicates infection and inflammation. Since MRSA is a bacterial infection, monitoring WBC levels helps assess the severity of the infection and response to treatment.

B. Send wound drainage for culture and sensitivity. A wound culture and sensitivity test confirm the presence of MRSA and determine the most effective antibiotic therapy. This is essential to ensure appropriate treatment and prevent antibiotic resistance.

C. Institute contact precautions for staff and visitors. MRSA is transmitted via direct contact, especially through wound drainage. Contact precautions include wearing gloves and gowns when handling the patient or contaminated materials to prevent the spread of infection.

D. Explain the purpose of a low bacteria diet. A low-bacteria diet (neutropenic diet) is used for immunocompromised patients, such as those undergoing chemotherapy, but it is not relevant for MRSA. The focus should be on infection control and wound care rather than dietary restrictions.

E. Use standard precautions and wear a mask. While standard precautions should always be followed, a mask is not necessary unless performing aerosol-generating procedures or if MRSA is present in the respiratory tract. In this case, contact precautions (gown and gloves) are the primary infection control measures.

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Correct Answer is B

Explanation

A. Muscle aches and pains. Muscle pain is not a primary concern related to melanoma recurrence. While melanoma can metastasize to other organs, localized muscle pain is not the most important characteristic to monitor post-resection.
B. Appearance of any moles. Malignant melanoma is strongly associated with abnormal moles. The client should monitor existing moles and new skin lesions using the ABCDE rule:Asymmetry, Border irregularity, Color variation, Diameter greater than 6 mm, Evolving changes (size, shape, or symptoms like itching or bleeding), Early detection of new or changing moles is critical for identifying recurrence or new melanoma development.
C. Pigmentation of the skin. Changes in overall skin pigmentation (such as tanning or lightening) are not a primary concern. Localized pigmentation changes around moles may indicate malignancy, but generalized pigmentation shifts are not the focus for melanoma monitoring.
D. Elasticity of the skin. Skin elasticity is affected by aging and sun exposure but is not a key factor in melanoma surveillance. Monitoring moles and skin lesions is far more important for early detection of recurrence.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

Based on the client's history, physical, and laboratory findings, the priority need will be to treat the infection (cellulitis). In addition, the client will need interventions to manage complications, especially deep tissue injury and impaired circulation.

Rationale:

The infection (cellulitis) is the primary concern, as indicated by redness, warmth, swelling, and systemic symptoms like muscle aches. Immediate antibiotic therapy is crucial.

Deep tissue injury is a potential complication due to prolonged inflammation, swelling, and impaired circulation, which can lead to tissue damage.

Impaired circulation is a significant risk in a client with diabetes and peripheral vascular disease, as it can slow healing and increase the likelihood of further complications such as ulcers or necrosis.

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An older adult client is admitted from a long-term care facility with purulent exudate draining from a sacral pressure ulcer is suspected to have methicillin-resistant Staphylococcus aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

The nurse should recognize which response is the immune system's reaction to a source of inflammation?

A nurse develops a delayed hypersensitivity reaction after wearing latex gloves. Which pathophysiologic process is involved in this type of hypersensitive reaction?

An older adult client comes to a free vaccination clinic requesting an influenza vaccination. Which action should the nurse implement?

The nurse is assessing a client's skin and notices a raised nodule on the right forearm that is tender and filled with purulent secretions. The healthcare provider diagnosed the abscess as a furuncle. Which pathological etiology places the client at risk for the development of a furuncle?

Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.