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Difficulty: MediumStandard and Transmission-Based Precautions

A practical nurse is assigned to care for a toddler who is newly admitted to the pediatric unit with suspected measles (rubeola). Which infection control interventions should the nurse implement? Select all that apply.

  1. Verify that the client is placed in a negative-pressure airborne infection isolation room.Answer
  2. Don a fit-tested N95 respirator before entering the client's room.Answer
  3. C
    Remove the N95 respirator immediately after providing care while still inside the client's room.
  4. D
    Wear a standard surgical face mask when providing care within 3 feet of the client's bed.
  5. Place a standard surgical mask on the client if transport to another department is necessary.Answer
  6. F
    Delegate the evaluation of the client's respiratory effort to an unlicensed assistive personnel.

Answer

The correct interventions include verifying the client is in a negative-pressure isolation room, donning a fit-tested N95 respirator prior to entry, and placing a standard surgical mask on the client during necessary transport.
Measles requires Airborne Precautions. Essential interventions include placing the client in a negative-pressure airborne infection isolation room to prevent infectious air from circulating, wearing a fit-tested N95 respirator to filter out suspended droplet nuclei, and placing a standard surgical mask on the client during transport to contain their outgoing respiratory secretions.

Step-by-Step Solution

1
Identify the pathogen and the required isolation precautions.
Measles (rubeola) is highly contagious and transmitted via the airborne route, requiring Airborne Precautions.
Airborne Precautions are designed to prevent the spread of infectious droplet nuclei that remain suspended in the air over long distances.
2
Determine the appropriate room assignment and personal protective equipment (PPE).
The client must be placed in a negative-pressure airborne infection isolation room. Staff must don an N95 respirator (or PAPR) before entering the room.
Negative pressure prevents contaminated air from escaping into surrounding areas. An N95 respirator filters out airborne infectious particles that a standard mask cannot block.
3
Identify safety protocols for transport and doffing of PPE.
The client must wear a standard surgical mask when transported outside the room. The nurse must remove the N95 respirator only after exiting the room and closing the door.
The client's mask contains their source respiratory secretions. Removing the N95 outside the isolation room protects the nurse from lingering airborne particles.
4
Differentiate the scope of practice for delegated tasks.
Evaluation of respiratory effort cannot be delegated to an unlicensed assistive personnel (UAP).
Evaluating a client's clinical status requires nursing knowledge and judgment, which strictly falls outside the UAP's scope of practice.

Key Concept

Airborne Precautions and Scope of Practice
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Topics

Standard and Transmission-Based Precautions

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