HESI 799 RN Exit Exam 2024 Verified Marking Scheme

HESI 799 RN Exit Exam 2024 Verified Marking Scheme 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-resistant 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. - ANSWER- a. Collect multiple site screening 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- resistant strains (MDRSP) of Staphylococcus aureus. A sputum culture is not indicated D) based on the client's history is a wound infection. 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) residual 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. - ANSWER- 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 extrudes to a suction device that exert negative pressure to remove excess wound fluid, reduce the bacterial count and stimulate granulation. The VAC is changed every other day or third day, not (A) depending on the stage of wound healing and emptied when full or weekly. The transparent wound dressing should extend 3 to 5 cm beyond the wound edges, not (B) to ensure and airtight seal. Adhesive removers leave a reduce that binder transparent film adherence (D) The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client's plan of care? a. Increase fluid intake to 3,000 ml/daily b. Administer O2 at 5L/mint per nasal cannula c. Maintain the client in a semi Fowler's position d. Provide frequent rest period. - ANSWER- Increase fluid intake to 3,000 ml/daily Rationale: The plan of care should include an increase in fluid intake (A) to liquefy and thin secretions for easier removal of thick pulmonary secretion which facilitates airway clearance. (B) should be implemented for signs of hypoxia (C) implemented to facilitate lung expansion, and (D) implemented for activity intolerance, but these interventions do not have the priority of (A) The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? a. Clearance around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle b. Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. c. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens. d. Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24 hours. - ANSWER- Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. Rationale: Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours is the correct procedure for collecting 24-hour urine specimen. Discarding even one voided specimen invalidate the test.