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 C

Explanation

A. A 70-year-old fair-skinned client who works as a secretary. While fair skin and older age increase skin cancer risk, indoor work minimizes UV exposure, which is the primary risk factor for skin cancer.
B. A 16-year-old dark-skinned client who tans in tanning beds once a week. Tanning bed use increases the risk of skin cancer, but darker skin has more melanin, which provides some UV protection. A fair-skinned person with prolonged outdoor exposure would be at higher risk.
C. A 65-year-old fair-skinned client who is a construction worker. This client has the highest risk due to chronic UV exposure from outdoor work, fair skin (which burns more easily), and older age (increased cumulative sun damage). Occupational sun exposure is a major risk factor for basal cell carcinoma, squamous cell carcinoma, and melanoma.
D. A 25-year-old dark-skinned client whose mother had skin cancer. Family history is a risk factor, but darker skin provides more UV protection. Additionally, younger age and less cumulative sun exposure make this client lower risk than an older, fair-skinned construction worker.

A. Instruct incentive spirometry use every hour. B. Encourage consumption of protein and vitamin C. C. Apply thromboembolism deterrent stockings (TED). D. Use Petroleum based lotion on legs

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

Instruct incentive spirometry use every hour (Nonessential): There is no indication of respiratory compromise, so incentive spirometry is not a priority for this client.

Encourage consumption of protein and vitamin C (Indicated): These nutrients support wound healing and immune function, which are important in managing infection and preventing further complications.

Apply thromboembolism deterrent stockings (TED) (Contraindicated): TED stockings may worsen symptoms if the client has cellulitis or a deep vein thrombosis (DVT), as compression can increase pain and impede circulation in an already swollen and inflamed limb.

Use petroleum-based lotion on legs (Contraindicated): Petroleum-based products can trap moisture and create an environment for bacterial growth, which is not suitable for a client with cellulitis or diabetes. Instead, a diabetic-safe moisturizer should be used while avoiding open wounds.

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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

Which client has the highest risk for developing skin cancer?

Correct Answer is C

Explanation

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.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}

Explanation

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