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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Peripheral neurovascular dysfunction. While some chemotherapy agents can cause neuropathy, the immediate risk of a vesicant (a drug that can cause severe tissue damage if it leaks) is extravasation, leading to skin and tissue damage, rather than direct neurovascular impairment.
B. Impaired skin integrity. Vesicants can cause severe tissue necrosis if they extravasate (leak into surrounding tissues). Leaving an IV in place for 72 hours increases the risk of infiltration or extravasation, which can lead to serious complications, including blistering, necrosis, and deep tissue injury. Proper IV site rotation and monitoring are essential to prevent skin and tissue damage.
C. Fluid volume excess. Fluid volume excess is not a direct risk related to vesicant chemotherapy. While some IV fluids can contribute to fluid overload, the primary concern with vesicants is extravasation and tissue damage.
D. Acute pain and anxiety. While pain and anxiety can occur if extravasation happens, the greatest clinical risk is the physical damage caused by tissue necrosis. Pain is a symptom of extravasation, but preventing skin and tissue injury is the priority.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
Rationale:
- Calculate total fat calories for each day:
- Day 1: 24×38=91224 \times 38 = 912 kJ
- Day 2: 22×38=83622 \times 38 = 836 kJ
- Day 3: 23×38=87423 \times 38 = 874 kJ
- Convert total daily calories to kJ:
- Day 1: 3,200×4.184=13,388.83,200 \times 4.184 = 13,388.8 kJ
- Day 2: 2,980×4.184=12,471.32,980 \times 4.184 = 12,471.3 kJ
- Day 3: 3,310×4.184=13,841.03,310 \times 4.184 = 13,841.0 kJ
- Calculate fat percentage:
- Day 1: (912/13388.8)×100=18.2%
- Day 2: (836/12471.3)×100=17.1%
- Day 3: (874/13841.0)×100=17.3%
Average fat percentage: (18.2+17.1+17.3)/3=17.5%
- Interpretation:
- The recommended fat intake range is 20-35% of total calories.
- The client's fat intake is 14-19%, which is below the recommended range.
- The client should increase his fat intake to meet nutritional needs.
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