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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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View Related questions

Correct Answer is A

Explanation

A. Not providing an interpreter for a client who speaks a different language may violate the client's right to understand their care, leading to potential legal issues regarding informed consent and patient safety.

B. A provider speaking to a client alone about suspected partner violence is appropriate as it ensures the client's privacy and safety during a sensitive discussion.

C. Prescribing a kosher meal tray for a client who practices the Orthodox Jewish faith is respectful and meets the dietary needs of the client, which is not a legal issue.

D. A client requesting that a nurse provide information to their partner is not inherently a legal issue, but the nurse must ensure that the client has consented to share their information to protect confidentiality.

Correct Answer is A

Explanation

A. Providing postmortem care is a task that can be delegated to assistive personnel, as it involves following established protocols and does not require clinical judgment.

B. Reinforcing discharge instructions requires clinical knowledge and assessment, making it inappropriate for delegation to an AP.

C. Interpreting deviations in a client's vital signs necessitates nursing judgment and clinical expertise, which an AP does not possess.

D. Inserting an NG tube is a skilled nursing procedure that requires assessment and decision-making, thus it should not be delegated to an AP.

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