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 A
Explanation
A. It is the main structural component of the dermis which provides strength and elasticity. Collagen is the primary protein in the dermis, responsible for maintaining skin strength, firmness, and elasticity. Sun exposure damages collagen fibers, leading to wrinkles, sagging skin, and premature aging.
B. It increases skin elasticity with the aging process. Collagen production decreases with age, leading to reduced skin elasticity and increased wrinkle formation. Sun damage accelerates this process by breaking down collagen fibers.
C. It forms the ridges and valleys which provide traction for grasping objects and surfaces. Friction ridges (fingerprints) are formed by the dermal papillae, not collagen. They provide grip and are genetically determined.
D. It is an extensive network of blood vessels that regulates body temperature. The dermis contains a network of blood vessels for temperature regulation, but this function is not related to collagen. Instead, collagen provides structural support to the skin.
Correct Answer is ["42"]
Explanation
Flowrate(gtt/min) = (Total volume×Drop factor)/Total time
= (500×20)/240
= 1000/240
= 41.67, round off to the nearest whole number
= 42
Thus, the nurse should regulate the infusion at 42 gtt/min.
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