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    HESI PN EXIT Proctored Exam 2

    While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?

    Explanation & Rationale

    A) Incorrect- reapplying a sterile non-adhesive dressing is not enough to address the infection. The nurse should also clean the wound, apply topical antimicrobial agents, and change the dressing regularly. B) Incorrect- limiting visitors to immediate family only is not a sufficient infection control measure. The nurse should also use standard precautions, such as wearing gloves, gowns, masks, and eye protection, and educate the visitors about hand hygiene and proper disposal of contaminated items. C) Correct- Administering prescribed antibiotics is the most important action because it can help treat the infection and prevent it from spreading to other parts of the body or to other people. MRSA is resistant to many common antibiotics, so it is essential to follow the prescription and monitor the client's response. D) Incorrect- requesting a nutrition consult is not a priority action. While nutrition is important for wound healing, it does not directly affect the infection. The nurse should first administer antibiotics and then assess the client's nutritional status and needs.

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