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Difficulty: MediumStandard and Transmission-Based Precautions

A client is transferred to the medical-surgical unit with active group A streptococcal pneumonia and a heavily draining sacral pressure injury that is positive for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following infection control interventions should the nurse implement? Select all that apply.

  1. Don a clean gown and gloves upon entering the client's room.Answer
  2. Wear a standard surgical mask when entering the client's room.Answer
  3. C
    Maintain the client in an airborne infection isolation room (AIIR) with negative air pressure.
  4. Place a standard surgical mask on the client if transport outside the room is necessary.Answer
  5. E
    Wear a fitted N95 particulate respirator when emptying the client's bedside commode.
  6. F
    Assign an unlicensed assistive personnel (UAP) to measure and document the dimensions of the sacral wound.

Answer

The correct interventions require combining Droplet precautions (surgical mask for the nurse upon entry, mask for the client during transport) and Contact precautions (gown and gloves upon entry).
This client requires both Droplet precautions for the streptococcal pneumonia and Contact precautions for the MRSA-positive draining wound. Droplet precautions require the nurse to wear a standard surgical mask when entering the room and mandate that the client wear a mask when transported outside the room to prevent transmission via respiratory secretions. Contact precautions require the nurse to don a clean gown and gloves prior to entering the client's environment to prevent transmission via direct contact with the wound or contaminated environmental surfaces.

Step-by-Step Solution

1
Identify the primary modes of transmission for the stated clinical conditions.
Group A streptococcal pneumonia is transmitted via large respiratory droplets. A heavily draining MRSA wound is transmitted via direct and indirect contact.
Accurate identification of transmission routes dictates the necessary isolation protocols.
2
Select the appropriate personal protective equipment (PPE) for the nurse based on the transmission modes.
Droplet precautions require a standard surgical mask. Contact precautions require a gown and gloves.
Concurrent infections require the nurse to apply all required PPE for both precaution tiers simultaneously.
3
Determine the environmental and transport requirements for the client.
A standard private room is sufficient. The client must wear a surgical mask during transport.
Negative-pressure rooms are reserved for airborne pathogens, not droplet or contact organisms. Source control (masking the client) prevents droplet spread outside the room.
4
Evaluate the appropriateness of care delegation regarding the client's infectious wound.
Delegating the wound measurement to UAP is incorrect.
Tasks requiring clinical assessment and judgment must remain the responsibility of the registered nurse.

Key Concept

Concurrent application of Droplet and Contact transmission-based precautions
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Topics

Standard and Transmission-Based Precautions

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