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    Hesi RN Exit proctored examQuestion 105
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    Hesi RN Exit proctored exam

    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. Reapply a sterile non-adhesive dressing: While maintaining a clean dressing is important to prevent further contamination, it does not address the underlying MRSA infection causing the wound to worsen. B. Administer prescribed antibiotics: Prompt administration of antibiotics is the priority because the wound is infected with MRSA and is enlarging, indicating active infection that requires systemic treatment to prevent sepsis and promote healing. C. Request a nutrition consult: Adequate nutrition supports wound healing, but it is a secondary intervention and does not immediately treat the infection or stop its progression. D. Limit visitors to immediate family only: Limiting visitors may reduce infection risk to others, but it does not directly treat the MRSA infection or address the acute worsening of the wound.

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