A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room to check the client's pulse. What personal protective equipment (PPE) should the nurse don?

Correct Answer: C

Rationale: In this scenario, the correct answer is option C) Gown. When caring for a client with MRSA in an abdominal wound, it is crucial for the nurse to wear a gown to prevent the transmission of the bacteria to themselves or other patients. A gown provides a barrier between the nurse's clothing and the infectious wound, reducing the risk of contamination. Option A) PAPR mask is not necessary in this situation unless there is a risk of airborne transmission, which is not typically associated with MRSA in a wound. Option B) Sterile gloves would be important when directly handling the wound or performing wound care, but for checking the pulse, regular gloves would suffice. Option D) Surgical mask is not adequate protection against MRSA, as it does not cover the nurse's body and clothing, leaving them vulnerable to exposure. Educationally, understanding the appropriate use of personal protective equipment is crucial for nurses to prevent the spread of infections in healthcare settings. By knowing when to use specific PPE items, nurses can protect themselves, their patients, and prevent the spread of harmful pathogens.

Correct Answer: C

Rationale: In the context of treating rheumatoid arthritis with medications, the expected outcome of decreased pain (option C) is the most appropriate choice among the given options. This is because medications used for rheumatoid arthritis primarily aim to reduce inflammation, which in turn helps alleviate pain associated with the condition. Option A, increased quality of life, is a broad outcome that can result from decreased pain and improved mobility, but it is not as specific to the direct effect of medications on pain relief. Option B, increased range of motion, is also a potential outcome of treatment, but it is more closely related to physical therapy and exercise rather than medication alone. Option D, cure the disease, is incorrect because currently, there is no known cure for rheumatoid arthritis. Medications can help manage symptoms, slow down disease progression, and improve quality of life, but they do not eliminate the disease entirely. In an educational context, understanding the expected outcomes of medication treatment for rheumatoid arthritis is crucial for healthcare professionals to effectively communicate with patients about treatment goals and manage expectations. It also underscores the importance of a multidimensional approach to care that includes medication management, physical therapy, lifestyle modifications, and patient education.

Correct Answer: B

Rationale: In this scenario, the correct term the nurse would use when documenting a wound covered by black and necrotic tissue is "B) Eschar." Eschar refers to the black, hard crust or scab that forms over a wound when dead skin tissue accumulates. This term specifically describes the necrotic tissue covering the wound, indicating a specific characteristic of the wound that needs to be documented accurately. Option A) Tunnelling refers to narrow passageways extending from the wound into the surrounding tissue, which is not the primary characteristic being described in this case. Option C) Blanching refers to the whitening of the skin when pressure is applied, typically seen in pressure injuries, which is not relevant to the scenario. Option D) Cellulitis is a bacterial infection of the skin and underlying tissues, which is not the same as the necrotic tissue covering the wound. Educationally, understanding wound characteristics and appropriate documentation is crucial in nursing practice to communicate effectively with other healthcare team members, track wound healing progress, and determine appropriate treatment interventions. Proper terminology usage ensures clear and accurate communication in the healthcare setting, promoting patient safety and quality care delivery.

Correct Answer: C

Rationale: In this scenario, option C, purulent drainage, is the correct answer indicating a possible infection in a client with AIDS. Purulent drainage is a sign of infection as it represents the presence of pus, which is a result of the body's immune response to an infection. In clients with AIDS, who have compromised immune systems, any signs of infection should be taken seriously and addressed promptly. Option A, respirations at 22 breaths per minute, is a normal respiratory rate and does not specifically indicate infection. Option B, client ambulating 20 feet, is a measure of mobility and does not directly relate to the presence of infection. Option D, oxygen saturation at 97% on room air, is within normal range and does not necessarily point towards infection. Educationally, it is crucial for healthcare providers to be able to recognize signs of infection in clients with AIDS due to their increased susceptibility to infections. Understanding these signs can assist in early detection and prompt treatment, which is vital in managing the health of clients with compromised immune systems.

Correct Answer: C

Rationale: In this scenario, the nurse should document the blood-tinged liquid from the wound as serosanguineous. Serosanguineous exudate is a common type of wound drainage that is a combination of blood and clear fluid. This type of drainage is expected in the immediate postoperative period and indicates normal healing. The option A, "creamy pus," is incorrect because it describes purulent exudate, which is thick, opaque, and typically yellow or green in color, indicating infection. Option B, "serous," is incorrect as serous drainage is clear and watery, without blood. Option D, "purulent exudate," is also incorrect as it describes pus, a sign of infection. From an educational perspective, understanding different types of wound drainage is crucial for nurses to assess wound healing and detect signs of infection early. Proper documentation of wound drainage helps healthcare providers track changes in the wound, monitor healing progress, and determine appropriate interventions. Nurses need to be able to accurately differentiate between different types of wound exudate to provide optimal care for their patients.