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 D

Explanation

A) Incorrect- Reviewing transcutaneous bilirubin levels is unrelated to the presence of an enlarged clitoris. Bilirubin levels are typically assessed to monitor jaundice in newborns.
B) Incorrect- Observing and palpating breast tissue for enlargement is not relevant to the condition of salt-wasting congenital adrenal hyperplasia. Breast tissue enlargement would not be associated with this hormonal disorder.
C) Incorrect- Assessing for signs of fluid retention and bilateral pedal edema is important for monitoring for other conditions, but it is not relevant to the enlarged clitoris seen in this specific scenario.
D) Correct- Salt-wasting congenital adrenal hyperplasia is a genetic disorder that results in a deficiency of certain enzymes required for cortisol and aldosterone production. This deficiency leads to an overproduction of androgens, which can cause virilization of female external genitalia. The enlarged clitoris is a result of increased androgen levels. Explaining this finding to the mother provides her with accurate information about the condition and its effects on the infant's anatomy.

A. Advise the client that lifestyle changes often takes several weeks to be effective. B. Encourage the client to exercise every day to eliminate bedtime wakefulness. C. Determine the amount of weight the client has lost since increasing activity. D. Ask the client for a description of the exercise schedule that is being followed.

Correct Answer is D

Explanation

In this scenario, the client is experiencing difficulty falling asleep at night, fatigue, and daytime sleepiness. These symptoms may indicate that the client's exercise routine is impacting their sleep patterns. By asking the client for a description of their exercise schedule, the nurse can gather important information about the timing, intensity, and duration of the client's exercise regimen.

Exercise has numerous benefits for sleep and overall health, but the timing and intensity of exercise can affect sleep patterns differently for individuals. Vigorous exercise close to bedtime may increase alertness and make it harder for some people to fall asleep.

Therefore, understanding the client's exercise routine will help the nurse assess if the timing or intensity of the exercise is contributing to the sleep issues.

Based on the information gathered, the nurse can provide appropriate guidance. This may include adjusting the timing of exercise to earlier in the day, reducing the intensity of exercise closer to bedtime, or considering other factors that may be contributing to the sleep difficulties, such as caffeine intake, stress, or environmental factors.

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Naxlex Comprehensive Predictor Exams

When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement?

Correct Answer is D

Explanation

A client tells the nurse about jogging every day with the hope of losing weight and sleeping better. The client states that it takes hours to fall asleep at night and is experiencing fatigue and sleepiness throughout the day. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?

The nurse is caring for a client newly diagnosed with emphysema. The nurse should prioritize which potential complication?

An adult client is admitted for severe pain in his side and back and is sent for an intravenous pyelogram. Which report from the client is the earliest indication to the nurse that the client is experiencing an adverse reaction to this procedure?

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention?

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer?