Examkin

Question

Difficulty: HardStandard and Transmission-Based Precautions

A practical nurse (PN) is participating in the admission care of a client who has just arrived at the medical-surgical unit with confirmed influenza A and a methicillin-resistant Staphylococcus aureus (MRSA) wound infection on the right heel. Which of the following actions are appropriate for the PN to take? Select all that apply.

  1. Place a standard surgical mask on the client if transport to another department is necessary.Answer
  2. Remove the disposable gown and gloves inside the client's room before stepping into the hallway.Answer
  3. Ensure that reusable medical equipment, such as a stethoscope, is dedicated solely to this client.Answer
  4. D
    Remove the standard surgical mask before doffing the contaminated isolation gown and gloves.
  5. E
    Apply disposable gloves before donning the isolation gown and standard surgical mask.
  6. F
    Perform the initial comprehensive nursing assessment to document the baseline condition of the MRSA wound.

Answer

The appropriate actions are placing a surgical mask on the client during transport, removing the gown and gloves inside the room, and dedicating reusable medical equipment to the client.
The client requires both Droplet Precautions for influenza A and Contact Precautions for the MRSA infection. Dedicating reusable equipment and doffing the gown and gloves inside the room are standard Contact Precaution measures necessary to prevent environmental contamination. Placing a surgical mask on the client during transport acts as essential source control for Droplet Precautions.

Step-by-Step Solution

1
Identify the required transmission-based precautions based on the client's diagnoses.
Influenza A requires Droplet Precautions, and the MRSA wound infection requires Contact Precautions.
Pathogen transmission routes dictate the specific isolation categories necessary to protect staff and other clients.
2
Determine the appropriate clinical actions and environmental controls for the combined precautions.
Appropriate actions include dedicating reusable equipment (Contact), removing gown/gloves before leaving the room (Contact), and placing a mask on the client during necessary transport (Droplet).
These combined measures act as source control for respiratory droplets and prevent direct transmission of infectious organisms from the client's immediate environment.
3
Evaluate the distractors against established PPE sequencing rules and the PN scope of practice.
The incorrect options violate the CDC sequence for donning and doffing PPE, and inappropriately assign an initial comprehensive assessment to the PN.
Improper PPE sequencing increases cross-contamination risks, and an RN must establish the initial baseline assessment.

Key Concept

Standard and Transmission-Based Precautions
Rate this question

Topics

Standard and Transmission-Based Precautions

More questions from this topic