1. The nurse is evaluating infection control practices performed by a spouse on a loved one who has methicillin-resistant Staphylococcus aureus (MRSA) in a right leg wound .Which actions indicate that the spouse requires further teaching? Select all that apply.
a. The spouse places soiled dressing supplies in the kitchen garbage can.
b. Disinfectant spray is used on the table where dressing supplies are prepared.
c. Clean gloves are used for wound dressing removal.
d. Sheets with wound drainage are washed in lukewarm water.
e. Dressing supplies are placed in a clean, dry location.
f. Routine hand hygiene is performed before and after care.
3. A nurse is caring for a client with advanced cancer. After reading the nursing note below, determine the nurse's next intervention.
a. PROGRESS NOTE: Client states, "The doctor says my chemotherapy isn't working anymore. They can only treat my symptoms now. I don't want to die in the hospital, I want to be in my own bed."
i. Reread the document on patient/client rights to the client
ii. Call the client's spouse to discuss the client's statements
iii. Tell the client that only in the hospital can there be adequate pain relief
iv. Explain the use of an advance directive to express the client's wishes.
4. Donald a 75-year-old was admitted to the hospital with severe dyspnea. He has a history of chronic alcohol abuse and cirrhosis. On admission, the nurse assesses the following: Thin, Chronically ill-appearing male. Blood pressure 108/62 mm Hg: pulse 118/min; RR 26/min; temperature 97.8°F (36.6°C). He has 3+ pitting generalized edema. His abdomen is distended and tight. He has orthopnea and complains of shortness of breath. Donald state that has he has been confined to his chair or couch for the past two weeks because of his breathing difficulty and general weakness.
a. Discuss what Donald's age and poor physical condition places him at risk for developing what type of issues?
b. What is significant about his edema?
c. What does a low albumin level indicate in Donald?
- Labs are drawn and your results are as follows;
o Sodium 128 mEq/L
o Chloride 90 mEq/L
o Total calcium 5.8 mEq/L
o Potassium 5.2 mEq/L
o Magnesium 2.7 mEq/L
o Phosphate 1.5 mEq/L
d. Please discuss the significance of the labs you received?
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