A nurse is preparing to perform a dressing change for a client who has a nondraining, stage III pressure ulcer that is infected with methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse take?
Wear protective eyewear.
Wear a mask when changing the dressing.
Use dedicated equipment for this client.
Turn on the HEPA filtration system.
The Correct Answer is C
A. Wearing protective eyewear is not typically required for dressing changes unless there is a risk of splashing or spraying of fluids.
B. A mask is not necessary for dressing changes unless there is a risk of respiratory droplet transmission, which is not applicable in this situation.
C. Using dedicated equipment for the client is crucial to prevent the spread of MRSA and ensure infection control.
D. Turning on the HEPA filtration system is not a standard practice for dressing changes and does not specifically address the infection control needs of the client with MRSA.
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Correct Answer is A
Explanation
A. Reporting the incident to the manager of the pharmacy is the appropriate action to ensure that the medication error is addressed and investigated properly, as this can help prevent future occurrences.
B. Incident reports should not be placed in the client's medical record, as they are separate documents meant for internal review and quality improvement.
C. Documenting the doubled dose in the client's medical record does not fulfill the legal requirements for reporting medication errors and could mislead future care providers about the medication administration history.
D. Contacting the nurse from the previous shift may be necessary for understanding the situation, but the priority is to report the incident properly to ensure patient safety.
Correct Answer is D
Explanation
A. Using only room numbers for client identification does not guarantee confidentiality, as room numbers can still be linked to specific individuals.
B. Logging assistive personnel into unit computers compromises security and violates confidentiality protocols. Each user should have a unique login.
C. Including a client’s name on a fax cover sheet is not recommended, as it exposes protected health information and can breach confidentiality.
D. Conducting change-of-shift report in a staff-only area protects client information from being overheard by unauthorized individuals, ensuring confidentiality.