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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 C

Explanation

A. While the nurse's notes may include observations about the client's condition, recording that an incident report was filed does not provide pertinent details regarding the client's care and is not appropriate.

B. Incident reports are confidential documents and should not be shared with the client's family, so providing a copy of the report is inappropriate.

C. Documenting the facts about the incident in the medical record is essential to provide a complete account of the client's care and any resulting changes or observations. This documentation is important for continuity of care and legal purposes.

D. Incident reports should not be placed in the medical record, as they are separate documents intended for internal review and quality assurance purposes.

Correct Answer is D

Explanation

A. Establishing the priorities of client care is part of the planning phase, not the implementation phase.

B. Comparing laboratory values is an assessment activity that occurs before planning and implementing care.

C. Asking the client about pain is an assessment activity used to gather information rather than an implementation task.

D. Reinforcing teaching about the client's diagnosis is an action that occurs during the implementation phase, as it involves executing the care plan and providing direct client education.

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