Exhibits

Review H and P, nurse's notes, flow chart, laboratory results, and prescriptions. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the PN should take to address that condition, and two parameters the PN should monitor to assess the client's progress.

A. Gloves
Gloves are essential when entering the room because MRSA (Methicillin-resistant Staphylococcus aureus) is a pathogen that can be transmitted through direct contact with contaminated surfaces or secretions. Gloves protect both the client and the PN from the spread of the infection and should be worn when touching the patient or surfaces/items in the room.
B. N95 Mask
An N95 mask is not required for MRSA infections unless there are concerns about airborne transmission, which is not typical for MRSA. MRSA transmission is primarily through direct or indirect contact rather than airborne routes, so an N95 mask is not necessary in this scenario.
C. Gown
A gown is required when there is a risk of contamination from the environment or the patient, especially with MRSA infections. It helps to protect the PN’s clothing and skin from coming into contact with any infectious materials from the surgical site.
D. Surgical Mask
A surgical mask is appropriate for MRSA to protect against droplets and to prevent the spread of infection. It is particularly useful if there is a risk of droplets from the patient or if the PN is performing procedures that might generate droplets.
E. Goggles
Goggles are not required for MRSA unless there is a specific risk of splash or spray that could potentially expose the PN’s eyes to infectious materials. In the context of a surgical site infection, goggles are not a standard part of the PPE unless additional procedures are being performed that involve splashes

Response 1

A. Fluid volume deficit
The client has signs of dehydration such as dry mucous membranes and a recent history of not having much to eat or drink in the past 2 days, which indicates a fluid volume deficit.

B. Respiratory alkalosis
There is no evidence to support respiratory alkalosis. The client's primary issues are related to infection and dehydration.

C. Hypoxia
The client’s oxygen saturation is 100% on 2 L/minute nasal cannula, so hypoxia is not a current issue.

D. Diarrhea
Diarrhea is not mentioned in the history, symptoms, or findings. It is not relevant to the client's condition.

Response 2

A. Decreased fluid intake
The client has not had much to eat or drink in the past 2 days, contributing directly to the fluid volume deficit.

B. Increased respiratory rate
While the client has an increased respiratory rate, it is a symptom of pneumonia rather than a cause of fluid volume deficit.

C. Infection
Although the client has pneumonia, the fluid volume deficit is more directly related to decreased fluid intake than to infection.

D. Heart disease
Heart disease is not mentioned and is not relevant to the client’s current presentation.