HESI 799 RN Exit Exam 2024 Updated Questions and Answers (2024 / 2025) (Verified Answers)PDF

1. A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resis- tant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.) a. Collect multiple site screening culture for MRSA b. Call healthcare provider for a prescription for linezolid (Zyrovix) c. Place the client on contact transmission precautions d. Obtain sputum specimen for culture and sensitivity e. Continue to monitor for client sign of infection.: ANS a. Collect multiple site screen- ing culture for MRSA c. Place the client on contact transmission precautions e. Continue to monitor for client sign of infection. Rationale: Until multi-site screening cultures come back negative (A), the client should be maintained on contact isolation(C) to minimize the risk for nosocomial infection. Linezolid (Zyvox), a broad spectrum anti-infecting, is not indicated, unless the client has an active skin structure infection cause by MRSA or multidrug- resis- tant strains (MDRSP) of Staphylococcus aureus. A sputum culture is not indicated D) based on the client's history is a wound infection. 2. A vacuum-assistive closure (VAC) device is being use to provide wound care for a client who has stage III pressure ulcer on a below-the- knee (BKA) resid- ual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device? a. Empty the device every 8 hours and change the dressing daily ensure sterility b. Extended the transparent film dressing only to edge of wound to prevent tension. c. Ensure the transparent dressing has no tears that might create vacuum leaks d. Use an adhesive remover when changing the dressing to promote comfort.- : ANS Ensure the transparent dressing has no tears that might create vacuum leak Rationale: The nurse should ensure that the VAC transparent film is intact, without tears or loose edges C) because a break in the seal resulting in drying the wound and decreasing the vacuum. The vacuum-assisted closure (VAC) device uses an open sponge in the wound bed, sealed with a transparent film dressing and tube