While changing a client's post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given a positive MRSA result, what is the most important action for the nurse to take?- Nurselytic

Question 1 of 5

While changing a client's post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given a positive MRSA result, what is the most important action for the nurse to take?

A. Force oral fluids B. Request a nutrition consult C. Initiate contact precautions D. Limit visitors to immediate family only

Correct Answer: C

Rationale: Initiating contact precautions is crucial in this situation to prevent the spread of MRSA infection. MRSA is a highly contagious bacterium that can spread through direct contact with an infected wound or by touching contaminated surfaces. By implementing contact precautions, the nurse can help contain the infection and protect other patients, healthcare workers, and visitors from being exposed to MRSA.

Question 2 of 5

While changing a client's post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given a positive MRSA result, what is the most important action for the nurse to take?

A. Force oral fluids B. Request a nutrition consult C. Initiate contact precautions D. Limit visitors to immediate family only

Correct Answer: C

Rationale: Initiating contact precautions is crucial in this situation to prevent the spread of MRSA infection. MRSA is a highly contagious bacterium that can spread through direct contact with an infected wound or by touching contaminated surfaces. By implementing contact precautions, the nurse can help contain the infection and protect other patients, healthcare workers, and visitors from being exposed to MRSA.

Question 3 of 5

The client, who is newly diagnosed with arteriosclerosis and is obese, is being educated by the nurse on reducing the risk of a heart attack or stroke. Which health promotion brochure should the nurse provide to this client?

A. Monitoring Your Blood Pressure at Home B. Smoking Cessation as a Lifelong Commitment C. Decreasing Cholesterol Levels Through Diet D. Stress Management for a Healthier You

Correct Answer: C

Rationale: The most significant risk factor contributing to arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Therefore, the most crucial brochure for the nurse to provide to the client focuses on decreasing cholesterol levels through diet to help reduce the risk of heart attack or stroke.

Question 4 of 5

At a motor vehicle collision site, a nurse applies pressure to a groin wound that is bleeding profusely until emergency personnel arrive. Subsequently, the client undergoes leg amputation and sues the nurse for malpractice. What is the most likely outcome of this lawsuit?

A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case. B. The lawsuit may be settled out of court, but the nurse's license is unlikely to be revoked. C. There will be no judgment against the nurse, as their actions were protected under the Good Samaritan Act. D. The client will win because the four elements of negligence (duty, breach, causation, and damages) cannot be proved.

Correct Answer: C

Rationale: The Good Samaritan Act shields healthcare professionals who act in good faith and offer reasonable care from malpractice claims, irrespective of the client's outcome. In this scenario, the nurse stopping to render aid at the accident scene and applying pressure to the bleeding groin wound would likely be covered by the Good Samaritan Act, protecting the nurse from legal repercussions related to the subsequent leg amputation.

Question 5 of 5

During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?

A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. B. The client tells the nurse that she does not have much of an appetite today. C. The nurse notes that there are numerous scatter rugs throughout the house. D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

Correct Answer: C

Rationale: The presence of numerous scatter rugs throughout the house poses a significant safety hazard to the client who is ambulating with a quad cane. These rugs increase the risk of tripping and falling, making it the most critical finding that needs immediate attention to prevent potential injuries and ensure the client's safety during ambulation.

Nurselytic

HESI RN

HESI RN

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