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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The property of the drugs that, if shared by both, indicates a need to closely monitor the client for drug toxicity is:

Highly protein bound.

When a drug is highly protein bound, it means that a significant portion of the drug molecules bind to proteins in the bloodstream. This binding can affect the availability and distribution of the drug in the body. If two drugs are highly protein bound and administered together, they may compete for binding sites on the proteins, leading to increased levels of unbound (free) drug in the bloodstream. This can result in higher drug concentrations and an increased risk of drug toxicity.

Closely monitoring the client for drug toxicity is necessary when drugs are highly protein bound because there is a potential for increased drug levels and associated adverse effects. Monitoring for signs and symptoms of drug toxicity, as well as routine laboratory tests to assess liver and kidney function, may be necessary in these cases.

The other properties listed do not necessarily indicate a need for closer monitoring for drug toxicity:

Low bioavailability refers to the fraction of an administered dose that reaches the systemic circulation in an active form. While low bioavailability can affect the effectiveness of a drug, it does not directly imply a need for closer monitoring for drug toxicity.
Short half-life refers to the time it takes for half of the drug concentration in the body to be eliminated. While drugs with short half-lives may require more frequent dosing, this property does not inherently suggest a need for closer monitoring for drug toxicity.
High therapeutic index indicates a wide margin of safety for a drug, meaning that the effective dose is significantly lower than the toxic dose. A high therapeutic index implies that the drug has a wide safety margin and is less likely to cause drug toxicity.

A. Ortolani maneuver causing a click at the hip joint. B. Plumb line test indicates fetal position curvature. C. Babinski test that reveals fanning out of toes. D. Moro test precipitating a startle response.

Correct Answer is A

Explanation

The Ortolani maneuver is a physical examination technique used to assess for developmental dysplasia of the hip (DDH) in newborns. During the maneuver, the nurse gently abducts the infant's hips and applies gentle pressure to detect any instability or "click" at the hip joint. A positive Ortolani maneuver, where a click or clunk is felt or heard, can indicate the presence of a hip dislocation or dysplasia.

Asymmetrical buttocks can be a sign of hip dysplasia in newborns, and a positive Ortolani maneuver is an important finding that suggests a potential hip joint problem. Reporting this assessment test result to the healthcare provider allows for further evaluation and appropriate management of the newborn's hip condition.

The Plumb line test, which assesses fetal position curvature, is not directly related to hip dysplasia and may not be significant in this context.

The Babinski test, which reveals fanning out of the toes, is used to assess the integrity of the infant's neurological system and is not specific to hip dysplasia.

The Moro test, also known as the startle response, is a reflex assessment used to evaluate the newborn's neurological and sensory function. While it is important to assess the overall neurological status of the newborn, the Moro test is not specific to hip dysplasia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning to administer two medications to a client at 0900. Which property of the drugs, if shared by both drugs, indicates a need to closely monitor the client for drug toxicity?

Correct Answer is C

Explanation

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider?

Correct Answer is A

Explanation

The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period?

An older client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900. What nursing action is most important?

A client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescriptions include radiation therapy. Which action should the nurse implement?

The school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In which position should the nurse place the child?

Exhibits here What should the nurse include in pre-discharge education for this child's parents? Select all that apply.

The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?

A client receives a prescription for itraconazole. Which information provided by the client requires additional instruction by the nurse?