At 0800, the nurse receives report on 5 clients. The nurse w… | MyMerci
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Standard/Transmission-Based Precautions/Surgical Asepsis

At 0800, the nurse receives report on 5 clients. The nurse will use the required PPE and perform hand hygiene before and after every client, so the order of care will not change the risk of cross-transmission. Place the clients in the order in which the nurse should see them, based on the urgency of each client's needs.

Ordered Response

Choose your responses, then check the answer.

Client with C. difficile on contact precautions, vitals at baseline, oral vancomycin due at 0900
Client with an MRSA wound on contact precautions, pain 7/10, PRN oxycodone due, vitals at baseline
Client with neutropenia (ANC 300/mm3), new temperature of 38.3 C, HR 104/min, BP 112/70 mm Hg
Client 2 days after appendectomy, pain 2/10, vitals at baseline, discharge teaching before 1500
Client with influenza on droplet precautions, SpO2 86% on 2 L/min, RR 32/min, using accessory muscles
Explanation
Because PPE and hand hygiene are used between every client, urgency alone decides the order. The client with influenza and SpO2 86% with accessory muscle use has a breathing problem and is first; the client with neutropenic fever needs antibiotics within about 1 hour and is second. Uncontrolled pain of 7/10 comes next, then the C. difficile medication due at 0900, and last the stable postoperative client whose teaching can occur any time before 1500.
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