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Zorluk: Çok zorStandard and Transmission-Based Precautions

A licensed practical nurse (LPN) is assigned to care for a client recently admitted from a long-term care facility. The client has an unstageable sacral pressure injury, a documented history of methicillin-resistant Staphylococcus aureus (MRSA), and has just developed profuse, watery diarrhea. A stool specimen is pending for Clostridioides difficile. Which actions should the LPN implement? Select all that apply.

  1. Don a fluid-resistant isolation gown and clean gloves before crossing the threshold into the room.Cevap
  2. B
    Wash hands meticulously with an alcohol-based hand rub for at least 20 seconds after providing client care.
  3. Ensure a dedicated disposable thermometer and blood pressure cuff are kept exclusively inside the client's room.Cevap
  4. D
    Remove the isolation gown and gloves in the hallway immediately after exiting the client's room.
  5. E
    Perform the initial comprehensive skin assessment of the unstageable sacral wound to establish a baseline.
  6. Maintain the client in a private room equipped with a dedicated toilet or bedside commode.Cevap

Cevap

The correct actions include donning an isolation gown and clean gloves before entering the room, ensuring dedicated disposable equipment is kept inside the room, and maintaining the client in a private room with a dedicated toilet.
The client's presentation of a multidrug-resistant organism (MRSA) and suspected C. difficile requires strict Contact and Enteric Precautions. The nurse must don a gown and gloves before entering the environment to prevent uniform contamination. To contain the pathogens, the client must be isolated in a private room with a dedicated toilet, and all assessment equipment (like stethoscopes and blood pressure cuffs) must remain in the room exclusively for that client's use.

Adım Adım Çözüm

1
Analyze the transmission risks presented by the client's condition.
The client requires Contact Precautions for MRSA and Enteric Contact Precautions for suspected C. difficile.
Different pathogens require specific infection control measures; suspected C. difficile mandates strict spore-elimination protocols.
2
Evaluate the personal protective equipment (PPE) and room assignment requirements.
A gown and gloves are required upon entry. A private room with a dedicated bathroom and dedicated medical equipment are necessary.
These environmental and physical barriers prevent the direct and indirect transmission of multidrug-resistant organisms and infectious diarrhea.
3
Determine the correct hand hygiene method for this specific clinical scenario.
Soap and water must be used instead of alcohol-based hand rub.
Alcohol does not eradicate C. difficile spores; the mechanical friction of washing with soap and water is required to physically remove them from the hands.
4
Review the proposed nursing interventions against the LPN/LVN scope of practice.
The initial comprehensive assessment of the pressure injury must be deferred to the RN.
While an LPN can perform routine wound care and gather ongoing data, initial assessments of complex or unstageable wounds require RN-level clinical judgment.

Anahtar Kavram

Integration of Enteric Contact Precautions, PPE protocols, and LPN scope of practice
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