While caring for a client after a small bowel resection, the nurse is informed that the client has a history of methicillin-resistant Staphylococcus aureus (MRSA). To reduce the risk of recurrence of the MRSA in the postoperative wound, which intervention is most important for the nurse to implement?
Report any increase in the white blood cell count.
Instruct the family to adhere to contact precautions.
Change the surgical dressing readily when soiled.
Wear a face mask while performing wound care.
The Correct Answer is B
MRSA is a highly contagious bacteria that can easily spread from person to person through direct contact or contact with contaminated surfaces. By instructing the family to adhere to contact precautions, the nurse can help prevent the spread of MRSA to the client's postoperative wound. Contact precautions typically involve wearing gloves and a gown when in direct contact with the client or the client's immediate environment.
While reporting any increase in the white blood cell count, changing the surgical dressing when soiled, and wearing a face mask during wound care are all important aspects of postoperative care, they are not specifically targeted at preventing the recurrence of MRSA. Adhering to contact precautions is the most effective measure to prevent the spread of MRSA and protect the client from further infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C,D,E
Explanation
A) This is because the client is experiencing an allergic reaction to piperacillin, which can be life-threatening. The nurse should stop the infusion immediately to prevent further exposure to the drug and assess vital signs to monitor for signs of anaphylaxis, such as hypotension, tachycardia, wheezes, or stridor.
B) Assessing vital signs is a priority to determine the severity of the reaction and the client's overall condition.
C) The nurse should contact the healthcare provider to report the situation and obtain orders for treatment, such as antihistamines, corticosteroids, or epinephrine.
D) The nurse should initiate an adverse event report to document the incident and follow the facility's protocol for reporting medication errors.
E) The nurse should also document the reaction to the drug in the client's chart and notify the pharmacy to avoid future administration of piperacillin or related antibiotics.
Correct Answer is B
Explanation
A.Protect the site from getting wet during bathing. While it is important to avoid prolonged soaking, gentle rinsing with water is usually allowed. Complete avoidance of water is not typically necessary.Gentle bathing is important for hygiene.
B.Gently patting the skin dry after rinsing with water is a good practice as it helps to minimize friction and irritation to the sensitive skin. Rubbing or scrubbing the skin should be avoided.
C. Applying moisturizers to prevent dry skin can be beneficial for overall skin health, but it is important to consult with the healthcare team and follow specific instructions regarding the use of moisturizers during radiation therapy. Certain types of moisturizers or creams may interfere with the radiation treatment or cause skin irritation. Frequent application is not always necessary. Over-hydration can soften the skin and increase vulnerability.
D.Using a sponge to debride the affected area is not recommended during radiation therapy. The skin in the radiation treatment field is already sensitive and prone to damage, and using a sponge for debridement can further traumatize the skin. It is important to avoid any abrasive or rough handling of the treated skin.
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