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 concern to the charge nurse is the appropriate action, as it ensures that the issue is addressed through proper channels. The charge nurse can investigate and determine if further action is needed, such as reviewing the medication administration process.
B. Questioning the nurse directly could lead to confrontations and is not the correct procedure for handling potential discrepancies in medication administration.
C. Notifying the pharmacy is unnecessary at this point because the issue concerns administration rather than medication supply or errors with the prescription.
D. While documenting the client’s report is important, simply documenting the client’s claim without notifying the charge nurse does not fully address the concern.
Correct Answer is A
Explanation
A. Morphine is classified as a Schedule II controlled substance due to its high potential for abuse and dependence, but it is accepted for medical use.
B. Schedule III substances have a lower potential for abuse than Schedule II, which does not apply to morphine.
C. Schedule I substances are considered to have no accepted medical use and a high potential for abuse, such as heroin, which does not include morphine.
D. Schedule IV substances have a lower abuse potential than Schedule III, making this classification incorrect for morphine.