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 B
Explanation
A. Offering suggestions demonstrates a directive approach rather than a laissez-faire style, which typically involves minimal guidance.
B. Encouraging the AP to decide how they would like to divide client care tasks exemplifies laissez-faire leadership, as it empowers team members to make decisions independently.
C. Instructing the AP to report hourly indicates a more authoritarian leadership style, as it sets specific expectations for accountability.
D. Providing constructive criticism suggests active involvement in guiding the AP’s performance, contrasting with the hands-off approach of laissez-faire leadership.
Correct Answer is D
Explanation
A. Postoperative emesis is a common occurrence and may not be critical unless it persists or is accompanied by other concerning signs.
B. While an 8 out of 10 pain level is significant, it can be managed with appropriate interventions and does not indicate an immediate complication.
C. Urinary output of 30 mL over 1 hour is low but does not necessarily indicate a critical condition that requires immediate intervention.
D. Mottling in the affected leg is a serious finding that may indicate compromised circulation or a thromboembolic event, making it the priority for reporting to the provider.