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Difficulty: MediumStandard and Transmission-Based Precautions

A medical-surgical nurse is developing a care plan for a client who is admitted with pneumonia caused by *Haemophilus influenzae* type b (Hib) and has a concurrent sacral wound infected with Vancomycin-resistant enterococci (VRE). Which interventions should the nurse include to maintain appropriate transmission-based precautions? Select all that apply.

  1. Instruct all personnel to don a surgical mask upon entering the client's room.Answer
  2. Keep a dedicated stethoscope and blood pressure cuff inside the client's room.Answer
  3. C
    Assign the client to a negative-pressure airborne infection isolation room.
  4. D
    Require staff to perform hand hygiene exclusively with soap and water upon exiting the room.
  5. Apply a standard surgical mask to the client when transport to the radiology department is necessary.Answer
  6. F
    Delegate the assessment and disposal of the client's soiled wound dressings to unlicensed assistive personnel (UAP).

Answer

The correct interventions include instructing personnel to wear a surgical mask, leaving dedicated equipment in the room, and placing a surgical mask on the client during transport.
The client requires a combination of Droplet and Contact precautions. Droplet precautions mandate that healthcare personnel wear a surgical mask upon entry and that the client wears one during transport to contain respiratory secretions. Contact precautions require the use of dedicated patient-care equipment to prevent indirect transmission of the pathogen to other clients via shared tools.

Step-by-Step Solution

1
Analyze the client's diagnoses and determine the required isolation categories.
Hib pneumonia requires Droplet precautions. VRE wound infection requires Contact precautions.
Accurate identification of transmission routes dictates the necessary personal protective equipment (PPE) and environmental controls.
2
Select interventions that align with Droplet precautions.
Identified the need for staff to wear surgical masks upon entry and for the client to wear a surgical mask during transport.
Droplet precautions target large respiratory particles that travel short distances, requiring barrier protection for the mucous membranes of nearby individuals.
3
Select interventions that align with Contact precautions.
Identified the need to dedicate reusable, non-critical equipment (stethoscope, blood pressure cuff) to the client's room.
Contact precautions prevent transmission of multidrug-resistant organisms spread through direct patient contact or indirect contact with contaminated environmental surfaces.
4
Evaluate the remaining options for clinical and delegation inaccuracies.
Eliminated the negative-pressure room (only for Airborne), exclusive soap-and-water handwashing (only for spore-forming organisms), and delegating wound assessment to UAP (outside scope of practice).
Ensures adherence to evidence-based infection control standards and safe delegation guidelines.

Key Concept

Clients with multiple transmissible infections require a combination of precautions. Droplet precautions require surgical masks for staff and for the client during transport. Contact precautions necessitate dedicated equipment and proper hand hygiene, though alcohol-based rubs remain acceptable unless spore-forming organisms are present.
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Topics

Standard and Transmission-Based Precautions

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