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Before you go in the room to change the dressing for your assigned patient, who has a stage 3 pressure injury infected with MRSA, your first priorities will be to
- A. Determine supplies needed for the dressing change.
- B. Obtain appropriate PPE for caring for a patient with MRSA.
- C. Review sterile technique to prevent contaminating the wound.
- D. Review how to assess a stage 3 pressure injury.
- E. Ask the patient how the other nurses have done the dressing change.
Correct Answer: B,C
Rationale: For an MRSA-infected wound, obtaining PPE and reviewing sterile technique are priorities to prevent transmission and further contamination.
You may also like to solve these questions
Classify the following wounds as either open or closed: A. Contusion, B. Abrasion, C. Laceration, D. Pressure injury
- A. A: Closed, B: Open, C: Open, D: Open
- B. A: Open, B: Closed, C: Closed, D: Closed
- C. A: Closed, B: Closed, C: Open, D: Open
- D. A: Open, B: Open, C: Closed, D: Closed
Correct Answer: A
Rationale: Contusions are closed (bruising under intact skin), while abrasions, lacerations, and pressure injuries are open (skin is broken).
In what order do wounds heal?
- A. Reconstruction phase, maturation phase, inflammatory phase
- B. Inflammatory phase, reconstruction phase, maturation phase
- C. Prodromal phase, symptoms phase, inflammatory phase, reconstruction phase
- D. Symptoms phase, maturation phase, inflammatory phase, reconstruction phase
Correct Answer: B
Rationale: Wounds heal in three phases: inflammatory (immediate response), reconstruction (tissue repair), and maturation (scar formation).
If a patient had a stage 3 pressure injury, you would expect to see which of the following on assessment?
- A. Erythema of intact skin that does not blanch and is not purple or maroon in color
- B. Intact serum-filled blisters and broken blisters with shallow, pink or red, moist ulcerations
- C. An open area that reveals damage to the epidermis, dermis, subcutaneous tissue, muscle, fascia, tendon, joint capsule, and bone
- D. An open area that extends through the epidermis, dermis, and subcutaneous tissue with possible undermining and tunneling
Correct Answer: D
Rationale: Stage 3 pressure injuries involve full-thickness loss of skin and subcutaneous tissue, often with undermining or tunneling.
Your patient with a stage 3 pressure injury infected with MRSA is on contact precautions. Which of the following PPE will you obtain when you enter his room?
- A. Gloves
- B. Gown
- C. Mask
- D. Goggles
Correct Answer: A,B
Rationale: Contact precautions for MRSA require gloves and a gown to prevent direct contact with the patient or contaminated surfaces.
Which are accurate statements about a deep tissue pressure injury?
- A. It may be caused by a medical device, such as a splint.
- B. It is deep red, maroon or purple colored, and does not blanch.
- C. It may be intact or nonintact skin.
- D. It is at least 2 cm deep or deeper.
- E. It is the result of prolonged pressure and/or shear force.
Correct Answer: A,B,C,E
Rationale: Deep tissue pressure injuries involve non-blanching discoloration, can be intact or nonintact, and result from pressure/shear, often from devices.