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A client is in contact isolation due to a stage IV coccyx wound infected with MRSA. The nurse plans interventions to prevent multiple infections.Which intervention is most appropriate to prevent the spread of MRSA to others?
- A. Change coccyx dressing after performing routine care.
- B. Change coccyx dressing before performing routine care.
- C. Restate the vital importance of performing hand hygiene.
- D. Perform coccyx dressing change in the nursing station.
Correct Answer: C
Rationale: Restate the vital importance of performing hand hygiene. The most effective way to prevent MRSA is frequent hand washing.
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While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion.Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?
- A. Hematocrit.
- B. Serum.
- C. Blood PT level.
- D. Neutrophil count.
Correct Answer: D
Rationale: Neutrophils are a type of white blood cell that play a key role in fighting infections. An elevated neutrophil count can indicate the presence of an infection. Therefore, before reporting the finding of a red, tender, and swollen wound at the site of the lesion to the healthcare provider, the nurse should note the client's neutrophil count.
After a week of bed rest, a client is being assisted to a chair for the first time.The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?
- A. Determine how the client feels.
- B. Support the client when rising.
- C. Offer a pair of non-skid socks.
- D. Place the chair by the bed.
Correct Answer: A
Rationale: After moving the client to a sitting position, the next step the nurse should implement is to determine how the client feels. This allows the nurse to assess for any dizziness, lightheadedness, or other symptoms that may indicate orthostatic hypotension or other issues.
An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops.What actions should the nurse take first?
- A. Obtain a do not resuscitate prescription.
- B. Set up a family conference to discuss the client's wishes.
- C. Discuss with the client her meaning of heroic measures.
- D. Consult the palliative care team about the client's care.
Correct Answer: C
Rationale: The nurse should first discuss with the client her meaning of heroic measures. This will help the nurse to understand the client's wishes and preferences for her care.
The nurse is planning to provide mouth care to an unconscious client.Which statement is accurate for implementing mouth care to this client?
- A. Brushing an unconscious client's teeth should be avoided.
- B. Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.
- C. Unconscious clients need less frequent mouth care than conscious clients.
- D. Positioning the unconscious client upright is the best method because they are not eating or drinking.
Correct Answer: B
Rationale: Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client. When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration.
A postoperative client has been prescribed three different analgesics for different levels of pain.What is the most important intervention the nurse should take when administering these medications to the client?
- A. Administer each medication at the same time to ensure pain relief.
- B. Administer the medication with the highest dose first, then the others.
- C. Administer the medications as ordered based on the client's pain level.
- D. Administer the medication with the longest duration of action
Correct Answer: C
Rationale: The most important intervention the nurse should take when administering these medications to the client is to assess the client's pain level and administer the appropriate medication based on the level of pain.