Level: Foundational
Difficulty: Easy
Subtopic: Standard precautions
NCLEX: A 52-year-old client on a medical-surgical unit is being evaluated for hospitalized care. Assessment data include…
Microbiology Safety and Infection Prevention and Control
Case Study
A 52-year-old client on a medical-surgical unit is being evaluated for hospitalized care. Assessment data include wound culture grows MRSA with spreading erythema. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that wound culture grows MRSA with spreading erythema.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that wound culture grows MRSA with spreading erythema.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that wound culture grows MRSA with spreading erythema.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.