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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?

A.

Wear protective eyewear.

B.

Wear a mask when changing the dressing.

C.

Use dedicated equipment for this client.

D.

Turn on the HEPA filtration system.

Answer and Explanation

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. Respecting the daughter's decision to refuse the transfusion aligns with the principles of patient autonomy and the authority granted through the durable power of attorney for health care, meaning the daughter's wishes must be followed.

B. Encouraging the daughter to allow the transfusion would undermine her role as the decision-maker and may cause unnecessary conflict, making this option inappropriate.

C. Discussing guardianship is not necessary or appropriate in this context, as the daughter has already been designated as the decision-maker, which negates the need for additional legal intervention.

D. Asking the provider to give consent for the transfusion contradicts the authority granted to the daughter, as she is the legally recognized decision-maker and has already made her choice.

Correct Answer is A

Explanation

A. Raisin toast is a bland carbohydrate that is generally well-tolerated and can help settle the stomach, making it a suitable choice for clients experiencing chemotherapy-induced nausea.

B. Soft-serve ice cream may be too rich and can upset the stomach for some clients undergoing chemotherapy, leading to increased nausea.

C. String cheese is high in fat and protein, which might not be well-tolerated during episodes of nausea, as heavy foods can exacerbate discomfort.

D. Hot tea may be soothing for some clients; however, certain herbal teas can sometimes provoke nausea or have an adverse effect, making it less ideal than bland carbohydrates.

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