The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel (UAP) providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. Which is the priority nursing action?

Advise the UAP to stop providing care so the nurse can assess the client's condition.

Determine why the UAP did not notify the nurse of the change in the client's condition.

Ask the UAP to position the client so the oral medications can be administered.

Explain to the UAP that changes in a client's condition should be reported immediately.

Answer and Explanation

The Correct Answer is A

A. Advise the UAP to stop providing care so the nurse can assess the client's condition: The client shows signs of acute deterioration, which may indicate a life-threatening event. Immediate assessment takes priority over continuing routine tasks or delegating care.

B. Determine why the UAP did not notify the nurse of the change in the client's condition: Investigating the UAP’s actions is important for accountability and education but is secondary to addressing the client’s urgent medical needs.

C. Ask the UAP to position the client so the oral medications can be administered: Administering medications is not the priority when the client is unstable. Ensuring patient safety and assessing the acute condition comes first.

D. Explain to the UAP that changes in a client's condition should be reported immediately: Educating the UAP is necessary to prevent future incidents but does not address the immediate need to evaluate and stabilize the deteriorating client.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Reapply a sterile non-adhesive dressing: While maintaining a clean dressing is important to prevent further contamination, it does not address the underlying MRSA infection causing the wound to worsen.

B. Administer prescribed antibiotics: Prompt administration of antibiotics is the priority because the wound is infected with MRSA and is enlarging, indicating active infection that requires systemic treatment to prevent sepsis and promote healing.

C. Request a nutrition consult: Adequate nutrition supports wound healing, but it is a secondary intervention and does not immediately treat the infection or stop its progression.

D. Limit visitors to immediate family only: Limiting visitors may reduce infection risk to others, but it does not directly treat the MRSA infection or address the acute worsening of the wound.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"E"}

Explanation

Rationale for correct choices:

• Cellulitis: The client presents with redness, warmth, swelling, and pain in the left lower leg, along with a small preceding cut. These findings are characteristic of cellulitis, a bacterial infection of the dermis and subcutaneous tissue, often following a breach in the skin barrier.

• Break in skin: The small cut noted above the lateral ankle provides an entry point for bacteria, explaining the localized infection. A break in skin is a common precursor to cellulitis, particularly in clients with diabetes or vascular compromise.

• Left lower leg erythema: Erythema indicates inflammation and infection, which are hallmark signs of cellulitis. The presence of erythema, along with swelling and warmth, supports the clinical diagnosis of a bacterial skin infection.

Rationale for incorrect choices:

• Left lower leg erythema (as a diagnosis option): Erythema alone describes a symptom rather than a medical diagnosis. While present, it does not capture the underlying bacterial infection requiring treatment.

• Break in skin (as a diagnosis option): A break in the skin is a risk factor or contributing event, not a formal diagnosis. It explains how infection occurred but does not replace the clinical diagnosis of cellulitis.

• Cool, pale left leg: This finding is more indicative of arterial insufficiency or ischemia rather than infection. The client’s affected leg is warm and erythematous, which contrasts with cool, pale tissue.

• Intact skin: Intact skin would not allow bacterial entry and does not explain the localized infection. The client has a visible small cut that preceded the erythema.

• Dry scaly skin: While common in peripheral vascular disease or chronic dermatologic conditions, dry scaly skin does not explain the acute signs of infection seen in this client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?

Correct Answer is B

Explanation

Patient Data Exhibits Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis ofdropdown would be explained by assessment findings of dropdown anddropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"E"}

Explanation

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