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 D
Explanation
A. Contacting the provider for instructions could delay immediate resuscitative efforts, which are required in the absence of a DNR order.
B. Consulting with the client’s family may not be effective in an emergency, as the living will is a legal document, and family members cannot override it without a DNR order.
C. Complying with the living will and letting the client expire naturally would be inappropriate without a formal DNR order in place.
D. Calling a code is the correct action because, legally, resuscitative efforts must be initiated in the absence of a written DNR order from the provider, despite the existence of a living will.
Correct Answer is C
Explanation
A. Administering pain medication before ambulation is an example of patient-centered care and pain management but does not specifically demonstrate fidelity, which relates to keeping promises and being trustworthy.
B. Stopping feeding when a client becomes short of breath is an appropriate response to prevent aspiration, but it is not an example of fidelity.
C. Telling a client she will return with a medication and following through with that commitment demonstrates fidelity by fulfilling a promise and showing reliability.
D. Dividing time and care between clients is part of effective time management, but it does not specifically represent fidelity, which emphasizes keeping promises to clients.