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Difficulty: MediumStandard and Transmission-Based Precautions

A licensed practical nurse is observing an assistive personnel (AP) conclude morning care for a client on contact precautions for a Methicillin-resistant *Staphylococcus aureus* (MRSA) infection. Which action by the AP requires immediate correction by the nurse?

  1. Removing gloves, exiting the client's room, and then removing the isolation gown in the hallway.Answer
  2. B
    Pinching the outside of the first glove near the wrist to gently peel it off inside out.
  3. C
    Rolling the contaminated isolation gown away from the body into a bundle prior to disposal.
  4. D
    Accepting the delegated task of measuring and emptying the client's urinary drainage bag.

Answer

The action that requires immediate correction is removing gloves, exiting the client's room, and then removing the isolation gown in the hallway.
The correct answer identifies that the assistive personnel is inappropriately removing personal protective equipment outside the client's room. To prevent the spread of infectious microorganisms, all personal protective equipment (except for respirators) must be removed and discarded inside the client's isolation room before transitioning to the hallway.

Step-by-Step Solution

1
Evaluate the scenario and the specific requirements for contact precautions.
Identify that the client has MRSA, requiring a gown and gloves for room entry, which must be safely removed before exiting the patient environment.
Understanding the mode of transmission is essential for applying the correct infection control protocols.
2
Analyze the action of removing the isolation gown in the hallway after exiting the room.
Determine that this behavior violates standard infection control principles because it transports contaminated equipment into a clean corridor.
Contaminated personal protective equipment must be removed and discarded inside the isolated environment to contain pathogens.
3
Assess the remaining actions (glove removal technique, gown rolling, and task delegation) for clinical accuracy.
Conclude that the glove and gown removal techniques are safe, and emptying a drainage bag is an appropriately delegated task.
Eliminating correct clinical actions isolates the single behavior that compromises unit safety and requires immediate nursing intervention.

Key Concept

Standard and Transmission-Based Precautions
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Topics

Standard and Transmission-Based Precautions

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