護理師照護一位有 MRSA 病史的病人,哪項發現需優先處理?
A nurse is caring for a client with a history of methicillin-resistant Staphylococcus aureus (MRSA). Which finding should the nurse prioritize?
- APatient complains of low-grade fever病患抱怨有低燒
- BPatient has dry skin病患皮膚乾燥
- CPatient is asking for pain medication病患要求止痛藥
- DPatient has a new, warm, erythematous wound✓ 正解病患有一處新的、溫熱且發紅的傷口
MRSA 是一種抗藥性金黃色葡萄球菌,常定殖於皮膚或鼻腔。當病人有 MRSA 病史且出現局部紅、腫、熱、痛的新傷口時,代表可能已發生活動性感染(Active infection)。護理師必須優先處理此發現,因為這涉及病人安全及病房內的交叉感染控制。需立即評估傷口狀況、執行傷口培養(Wound culture),並採取接觸隔離(Contact Precautions)以防擴散。
MRSA is a drug-resistant Staphylococcus aureus that frequently colonizes the skin or nares. When a client with a history of MRSA presents with a new wound that is red, swollen, warm, and painful, an active infection may have occurred. The nurse must address this finding first, as it has implications for client safety and infection control on the unit. Immediate assessment of the wound, wound culture, and contact precautions are required to prevent spread.