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?
Reapply a sterile non-adhesive dressing.
Limit visitors to immediate family only.
Administer prescribed antibiotics.
Request a nutrition consult.
The Correct Answer is C
A) Incorrect- reapplying a sterile non-adhesive dressing is not enough to address the infection.
The nurse should also clean the wound, apply topical antimicrobial agents, and change the dressing regularly.
B) Incorrect- limiting visitors to immediate family only is not a sufficient infection control measure. The nurse should also use standard precautions, such as wearing gloves, gowns, masks,
and eye protection, and educate the visitors about hand hygiene and proper disposal of contaminated items.
C) Correct- Administering prescribed antibiotics is the most important action because it can help treat the infection and prevent it from spreading to other parts of the body or to other people. MRSA is resistant to many common antibiotics, so it is essential to follow the prescription and monitor the client's response.
D) Incorrect- requesting a nutrition consult is not a priority action. While nutrition is important for wound healing, it does not directly affect the infection. The nurse should first administer antibiotics and then assess the client's nutritional status and needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Troponin I and CK-MB are cardiac enzymes that are released into the bloodstream when the heart muscle is injured or necrotic. Elevated levels of these enzymes indicate that the client has suffered a myocardial infarction (MI) or heart atack. The damaged heart tissue can impair the electrical conduction system of the heart and cause abnormal heart rhythms or dysrhythmias, which can be life-threatening. The PN should monitor the client's cardiac status closely and report any changes to the charge nurse.
The other options are not correct because:
- The client is not at risk for pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot or other material. Pulmonary embolism does not cause elevated cardiac enzymes, but it can cause chest pain, shortness of breath, and hypoxia.
- The client is not at risk for recurrent long-term angina pain, which is chest pain caused by reduced blood flow to the heart muscle due to narrowed or blocked coronary arteries. Angina pain does not cause elevated cardiac enzymes, but it can be a warning sign of an impending MI.
- The lab results do not indicate risk factors for transient ischemic atack (TIA), which is a temporary interruption of blood flow to a part of the brain due to a clot or plaque. TIA does not cause elevated cardiac enzymes, but it can cause neurological symptoms such as weakness, numbness, or speech difficulties.
Correct Answer is C
Explanation
A) Incorrect- Pupillary response is not relevant to the assessment of mesalamine's effectiveness.
Pupillary response is often assessed in neurological or ophthalmic evaluations and is not a direct measure of gastrointestinal function or the response to mesalamine therapy.
B) Incorrect- Peripheral pulses are not directly affected by mesalamine therapy, and monitoring them would not provide insight into the medication's effectiveness. Peripheral pulses are
typically assessed to evaluate the circulatory status and are not specific to the evaluation of gastrointestinal conditions.
C) Correct- Mesalamine is a medication commonly used to treat inflammatory bowel disease (IBD), such as Crohn's disease and ulcerative colitis. It helps to reduce inflammation in the gastrointestinal tract. Monitoring bowel patterns is important to assess the effectiveness of mesalamine in managing the symptoms of these conditions.
D) Incorrect- Oxygen saturation is a measure of the amount of oxygen in the blood and is used to assess respiratory function. While oxygen saturation is important for overall patient assessment, it is not directly related to mesalamine's effectiveness in treating inflammatory bowel disease.
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