Level: Clinical
Difficulty: Medium
Subtopic: Transmission-based precautions
NCLEX: A 71-year-old client in a long-term care facility is being evaluated for communicable respiratory infection. Asse…
Microbiology Safety and Infection Prevention and Control
Case Study
A 71-year-old client in a long-term care facility is being evaluated for communicable respiratory infection. 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. Routine data unchanged from the prior assessment.
D. The new finding that wound culture grows MRSA with spreading erythema.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that wound culture grows MRSA with spreading erythema.
Rationale
Correct answer: D. 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.