A clinical team is preparing a unit to receive a direct admission from an outpatient clinic. The client has a history of night sweats and hemoptysis, and a chest radiograph shows upper lobe cavitary lesions. Additionally, the clinic report notes a heavily draining sacral wound that recently cultured positive for Methicillin-resistant Staphylococcus aureus (MRSA). Which of the following infection control interventions should the receiving nurse implement? Select all that apply.
- Admit the client to a single-occupancy room that maintains negative air pressure relative to the adjacent corridor.Answer
- Don a particulate respirator (e.g., N95), gown, gloves, and eye protection before performing wound irrigation.Answer
- CDirect the transport staff to apply a fitted N95 respirator on the client prior to moving them to the radiology suite.
- DRemove the isolation gown and gloves in the hallway immediately after exiting the client's room.
- Store a dedicated stethoscope, thermometer, and blood pressure cuff inside the client's room for their exclusive use.Answer
- FDelegate the evaluation of the sacral wound's purulent drainage to the unlicensed assistive personnel (UAP) during routine vital signs.
Answer
The nurse should admit the client to a negative-pressure room, don an N95 respirator, gown, gloves, and eye protection for wound irrigation, and store dedicated medical equipment inside the client's room.
The client's presentation requires a combination of Airborne Precautions (due to suspected pulmonary tuberculosis indicated by night sweats, hemoptysis, and cavitary lesions) and Contact Precautions (due to the heavily draining MRSA wound). Airborne precautions mandate a single-occupancy negative-pressure room and the use of an N95 particulate respirator by healthcare workers. Contact precautions require a gown and gloves upon room entry and dedicating reusable equipment (like a stethoscope) to the client to prevent cross-contamination. Furthermore, because wound irrigation generates splashes, eye protection (e.g., a face shield or goggles) is required as part of Standard Precautions.
Step-by-Step Solution
Key Concept
Clients with multiple infectious processes require combined transmission-based precautions, alongside standard precautions based on anticipated exposure to body fluids.