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Difficulty: MediumStandard and Transmission-Based Precautions

A charge nurse is observing a newly licensed nurse prepare to care for a client who has suspected active pulmonary tuberculosis and a sacral wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which statements by the newly licensed nurse indicate a correct understanding of the required precautions? (Select all that apply.)

  1. I will wear a fit-tested N95 respirator, a disposable gown, and gloves when entering the client's room.Answer
  2. During transport to another department, the client must wear a standard surgical mask.Answer
  3. I should place dedicated patient-care equipment, such as a stethoscope, inside the client's room.Answer
  4. D
    The client's room door may be left open slightly to allow for continuous observation.
  5. E
    I must perform hand hygiene with soap and water rather than an alcohol-based hand rub after providing care.
  6. F
    I will ensure the client is placed in a room with positive-pressure airflow.

Answer

The correct statements are that the nurse must wear a fit-tested N95 respirator along with a gown and gloves, the client must wear a standard surgical mask during transport, and dedicated patient-care equipment must be placed inside the room.
When a client has multiple infections, the nurse must adhere to the precautions required for all of them. Active pulmonary tuberculosis requires airborne precautions, which mandate the use of a fit-tested N95 respirator, placement in a negative-pressure Airborne Infection Isolation Room (AIIR) with the door kept completely closed, and placing a standard surgical mask on the client if transport is necessary. The MRSA wound infection requires contact precautions, which mandate donning a disposable gown and gloves upon entering the room and dedicating patient-care equipment (such as a stethoscope or blood pressure cuff) to that specific room to prevent cross-contamination. Hand hygiene with an alcohol-based hand rub is appropriate for MRSA unless the hands are visibly soiled.

Step-by-Step Solution

1
Identify the transmission-based isolation requirements for all of the client's diagnoses.
Active pulmonary tuberculosis requires airborne precautions, while the MRSA wound infection requires contact precautions.
When a client has multiple infectious processes, the nurse must implement the required precautions for all concurrent infections simultaneously.
2
Evaluate each statement against the standard guidelines for combining airborne and contact precautions.
Statements describing the use of an N95 respirator with a gown and gloves, masking the client during transport, and using dedicated equipment align perfectly with established infection control protocols.
Nursing actions must comply with evidence-based practice to protect healthcare workers, the client, and other individuals in the facility.
3
Identify and exclude statements that reflect unsafe practices or clinical misconceptions.
Statements regarding an open door, a mandate for soap and water for MRSA, and positive-pressure airflow violate established isolation guidelines.
Recognizing unsafe practices is crucial to maintaining a safe care environment and preventing the spread of healthcare-associated infections.

Key Concept

Clients with multiple transmissible infections require the simultaneous implementation of all applicable isolation categories. Active pulmonary tuberculosis necessitates airborne precautions (N95, negative pressure, door closed), while MRSA necessitates contact precautions (gown, gloves, dedicated equipment).
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Topics

Standard and Transmission-Based Precautions

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