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 A

Explanation

A. Staphylococcus aureus abscess around a hair follicle. A furuncle, or boil, is a deep infection of a hair follicle caused by Staphylococcus aureus. It presents as a painful, pus-filled nodule due to bacterial invasion and inflammation. Poor hygiene, friction, or immune suppression can increase susceptibility.
B. Insect or spider bite that becomes infected. While insect bites can introduce bacteria into the skin, they do not directly cause furuncles. Secondary infection may occur, but furuncles specifically arise from infected hair follicles, not bites.
C. Sexual contact with an infected partner. Furuncles are not sexually transmitted infections. While skin-to-skin contact can spread Staphylococcus aureus, furuncles are not a direct result of sexual activity.
D. Inadequate blood supply to the area. Poor circulation can impair wound healing and increase infection risk, but furuncles result from bacterial infection of a hair follicle rather than ischemia.

A. Immediate allergic reaction mediated by sensitized mast cells. B. Antigen-antibody complexes deposit in tissues activating inflammation. C. T-cells sensitization initiates the macrophage release of cytokines causing a delayed reaction. D. Antibodies are formed against antigens on cell surfaces.

Correct Answer is C

Explanation

A. Immediate allergic reaction mediated by sensitized mast cells. This describes a Type I hypersensitivity reaction, which is an immediate allergic reaction. It involves IgE antibodies and mast cell degranulation, leading to symptoms such as hives, anaphylaxis, and respiratory distress. Latex allergies can involve Type I reactions, but delayed hypersensitivity is a Type IV reaction.
B. Antigen-antibody complexes deposit in tissues activating inflammation. This describes a Type III hypersensitivity reaction, which involves immune complex deposition leading to inflammation, as seen in lupus or serum sickness. Latex allergies do not involve immune complex deposition.
C. T-cells sensitization initiates the macrophage release of cytokines causing a delayed reaction. This describes a Type IV hypersensitivity reaction, which is a delayed-type hypersensitivity (DTH) mediated by T-cells rather than antibodies. In latex-induced delayed hypersensitivity, T-cells recognize latex proteins and release cytokines, leading to localized skin inflammation, rash, and itching, typically 24–48 hours after exposure.
D. Antibodies are formed against antigens on cell surfaces. This describes a Type II hypersensitivity reaction, which involves antibody-mediated destruction of cells, as seen in hemolytic anemia or blood transfusion reactions. Latex allergies do not involve direct antibody attack on cells.

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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

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?

Correct Answer is A

Explanation

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

Correct Answer is C

Explanation

Exhibits The nurse reviews the client's data. Which factor(s) place the client at greatest risk for skin injuries? Select all that apply.

Which assessment finding of an older adult client should the nurse associate with normal aging?

Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

Which client has the highest risk for developing skin cancer?

The nurse is assessing the nutritional status of a group of clients in a long term care facility. Which pathophysiological process poses the highest risk for malnutrition in this population?

Exhibits The nurse reviews the client's data. After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.

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