Question

Difficulty: HardStandard and Transmission-Based Precautions

A nurse is formulating a care plan for a client admitted with severe, watery diarrhea who is awaiting stool culture results for suspected Clostridioides difficile (C. diff). The client also has an active methicillin-resistant Staphylococcus aureus (MRSA) infection in a sacral pressure injury. Which of the following infection control interventions are appropriate to include in the plan of care? Select all that apply.

  1. Assign the client to a private room with a dedicated bathroom.Answer
  2. B
    Use an alcohol-based hand sanitizer for hand hygiene after removing gloves.
  3. C
    Wear an N95 respirator mask when entering the client's room.
  4. Keep a dedicated stethoscope and blood pressure cuff inside the client's room.Answer
  5. E
    Delegate the initial education of family members regarding isolation rules to the unlicensed assistive personnel (UAP).
  6. Don a disposable gown and clean gloves before entering the client's room.Answer

Answer

The correct interventions are assigning the client to a private room with a dedicated bathroom, keeping dedicated assessment equipment inside the room, and donning a disposable gown and clean gloves before entering.
The client requires Contact Precautions for MRSA and special enteric precautions for suspected C. diff. Safe and effective care includes a private room with a dedicated bathroom, donning a gown and gloves upon entry, and leaving dedicated medical equipment in the room to prevent cross-contamination.

Step-by-Step Solution

1
Identify the transmission route for the client's suspected and confirmed pathogens.
MRSA and C. diff both require Contact Precautions. C. diff specifically requires special enteric precautions (soap and water handwashing).
Accurate identification of the transmission route dictates the necessary personal protective equipment (PPE) and room assignment.
2
Evaluate the room assignment and equipment requirements for Contact Precautions.
A private room with a dedicated bathroom and dedicated medical equipment (stethoscope, blood pressure cuff) are required.
These measures prevent the physical transfer of microorganisms to other clients and shared areas.
3
Assess the appropriateness of PPE, hand hygiene methods, and delegation.
Gowns and gloves are needed upon entry. Alcohol rubs are ineffective against spores. Teaching cannot be delegated to UAP.
Nursing scope of practice prohibits delegating initial education, and C. diff spores require mechanical friction with soap to be effectively removed.

Key Concept

Standard and Transmission-Based Precautions
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