A 7-year-old child is admitted to the pediatric unit with a confirmed diagnosis of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) skin and soft tissue infection. Which nursing intervention should be the priority?
The child presents with multiple purulent lesions on the arms and legs, fever of 101.8°F (38.8°C), and elevated white blood cell count.
1Administer prescribed methicillin intravenously as ordered
2Apply topical antibiotic ointment to all affected areas
3Implement contact precautions and ensure proper hand hygiene✓ 정답
4Encourage increased fluid intake to prevent dehydration
해설
Contact precautions and hand hygiene are the priority to prevent transmission of CA-MRSA in healthcare settings. Other options are incorrect as methicillin is ineffective against MRSA, topical antibiotics are insufficient for systemic infection, and fluid intake is supportive but not immediate.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a patient with a confirmed Community-Associated Methicillin-Resistant Staphylococcus aureus (CA-MRSA) infection. The core principle is Infection Control and Prevention. MRSA is a multidrug-resistant organism (MDRO) that spreads primarily via direct contact. In any healthcare setting, the Key Point! is that safety and prevention of transmission to other patients, staff, and visitors take precedence over most other interventions.
Answer Rationale: The correct answer is ③ Implement contact precautions and ensure proper hand hygiene. This is the immediate priority because:
1. Key Point!Standard and Transmission-Based Precautions are the foundation of safe nursing practice. For MRSA, Contact Precautions (gown and gloves for direct patient/environment contact) are required to contain the pathogen.
2. Hand Hygiene is the single most effective measure to prevent the spread of healthcare-associated infections (HAIs). This must be reinforced for all staff and visitors.
3. The child has a systemic infection (fever, elevated WBC) with purulent lesions, which are reservoirs for bacteria. Containing this source is critical before proceeding with other care.
Distractor Analysis:
Watch out for confusion! ① Administer prescribed methicillin intravenously as ordered: This is incorrect because MRSA is, by definition, resistant to methicillin and other beta-lactam antibiotics (e.g., penicillins, cephalosporins). Administering it would be ineffective and a medication error. The appropriate treatment for CA-MRSA skin infections often involves antibiotics like Clindamycin, Trimethoprim-sulfamethoxazole (TMP-SMX), or Vancomycin for severe cases.
② Apply topical antibiotic ointment to all affected areas: While topical Mupirocin may be used for MRSA decolonization in some cases, it is not the priority for an active, systemic infection presenting with fever and multiple lesions. This is a supportive measure, not the immediate safety priority.
④ Encourage increased fluid intake to prevent dehydration: Managing fever and preventing dehydration is an important supportive nursing intervention. However, it is not the priority when there is an immediate risk of transmitting a dangerous, drug-resistant infection to others in the unit.
Related Concepts: The nursing process dictates that safety (preventing harm) is always a top priority. This aligns with the "Safety and Infection Control" client needs category on the NCLEX-RN. Remember the hierarchy: first, contain the hazard; then, treat the patient; and concurrently, provide supportive care.
Concept Summary
Concept
Key Takeaway
CA-MRSA
Methicillin-resistant Staph. aureus acquired outside healthcare settings. Often presents as skin/soft tissue infections (boils, abscesses).
Contact Precautions
Required for MDROs like MRSA. Use gown & gloves for contact with patient or their immediate environment.
Infection Control Priority
Preventing transmission is the #1 nursing priority for a patient with a known communicable, drug-resistant infection.
MRSA Treatment
Methicillin is ineffective. Common drugs: TMP-SMX, Clindamycin, Doxycycline, Vancomycin (IV for severe cases).
Side-by-Side Comparison!
Precaution Type
Used For
Key Interventions
Contact Precautions
MDROs (MRSA, VRE), C. diff, major wound infections
Gown & gloves for contact. Dedicated equipment if possible.
Droplet Precautions
Influenza, pertussis, meningococcal meningitis
Surgical mask within 3 feet/1 meter of patient. Patient wears mask during transport.
N95 respirator or PAPR. Negative pressure isolation room.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: Staphylococcus aureus is a gram-positive coccus. MRSA strains possess the mecA gene, which codes for an altered penicillin-binding protein (PBP2a), making them resistant to all beta-lactam antibiotics.
Pharmacology: Know first-line agents for CA-MRSA: Oral - TMP-SMX, Doxycycline, Clindamycin. IV - Vancomycin, Daptomycin, Linezolid.
Lab Value: Elevated White Blood Cell (WBC) Count (normal: 5,000-10,000 cells/mm³) indicates the body's systemic inflammatory response to infection.
Memory Tips
Priority Acronym: Safety first! For infections, think Stop the Spread (Contact Precautions) before Starting treatment.
MRSA Drug Mnemonic: "MRSA hates METH" – reminds you that Methicillin does NOT work. Think of other drug classes: "Very Carefully Treat Serious Disease" (Vancomycin, Clindamycin, TMP-SMX, Daptomycin).
High-Frequency NCLEX Topics
NCLEX heavily tests Transmission-Based Precautions. You must know which precaution matches which disease. Expect questions that ask for the "first," "priority," or "most important" action. The answer is often an infection control measure when a communicable disease or MDRO is involved.
Watch Out for Question Variations!
Instead of asking for the priority intervention, the question might ask: "The nurse should initiate which type of isolation?" (Answer: Contact Precautions).
The scenario could change to a post-operative wound infection with MRSA, testing the same concept.
It might ask about patient/family education: "Which statement by the parent indicates understanding of teaching?" Correct answer would involve hand hygiene and not sharing personal items.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse receiving a report on Jason, a 7-year-old newly admitted with fever and painful "spider bites" on his legs that are actually CA-MRSA abscesses. He's in a semi-private room.
Nursing Intervention Strategy:
Immediate Action (Priority): Upon confirmation of MRSA, don appropriate PPE (gown & gloves), place a "Contact Precautions" sign on the door, and ensure a dedicated stethoscope and blood pressure cuff are in the room. Instruct the family on hand hygiene with soap and water or alcohol-based sanitizer.
Assessment & Care: Complete your assessment while maintaining precautions. Obtain cultures if not done. Administer prescribed non-beta-lactam antibiotics (e.g., clindamycin) on time. Monitor vital signs, especially temperature. Assess pain from lesions and provide analgesia.
Wound Care: Perform wound care with sterile technique. Dressings with purulent drainage must be disposed of as biohazardous waste. Teach the child and family not to touch or squeeze the lesions.
Supportive Care & Education: Encourage fluids and nutritious foods. Educate the family that CA-MRSA is often spread through close skin-to-skin contact and sharing personal items (towels, razors, sports equipment). Stress the importance of completing the full course of antibiotics.
Patient Safety and Precautions:
Room Placement: Ideally, place the patient in a private room. If not available (as in this scenario), cohort with another patient with the same organism.
Transport: Limit transport. If necessary, cover infected sites with clean dressings and ensure the patient performs hand hygiene.
Environmental Cleaning: High-touch surfaces in the room must be cleaned and disaminated daily with an EPA-approved disinfectant effective against MRSA.
Nursing Procedure & Medication FlowProcedure: Implementing Contact Precautions
1. Perform hand hygiene before entering the room.
2. Don a clean gown and gloves before any contact with the patient or their environment (bed rails, bedside table).
3. Provide care.
4. Remove gloves and gown carefully inside the room, discard in designated container.
5. Perform hand hygiene immediately after removing PPE and upon exiting the room.
Medication: Vancomycin IV Administration (if ordered for severe infection)
- Must be infused slowly (over at least 60 minutes) to prevent Red Man Syndrome (histamine-mediated reaction causing flushing, pruritus, hypotension).
- Monitor trough levels (drawn just before the next dose) to ensure therapeutic efficacy and avoid nephrotoxicity/ototoxicity.
A Word from Your Senior Nurse
"In the real world, MRSA is everywhere in our communities and hospitals. Your role as a nurse is to be a barrier against its spread. Never underestimate the power of simple, consistent hand hygiene—it saves lives. When you see 'MRSA' on a chart, your brain should immediately flash: 'Contact Precautions are my first move.' This protects your other vulnerable patients, your colleagues, and yourself. Mastering this safety-first mindset is what separates a good test-taker from an excellent nurse."
Contact Precautions — A type of transmission-based precaution used for diseases spread by direct or indirect contact (e.g., MRSA, VRE, C. diff). Requires use of gown and gloves.
CA-MRSA (Community-Associated MRSA) — Methicillin-resistant Staphylococcus aureus infections occurring in healthy individuals without recent hospitalization or healthcare exposure. Often presents as skin and soft tissue infections.
Hand Hygiene — The most critical measure to prevent the spread of pathogens in healthcare settings. Includes washing with soap and water or using alcohol-based hand rub.
Multidrug-Resistant Organism — Bacteria that are resistant to one or more classes of antimicrobial agents, making infections difficult to treat. Examples include MRSA and VRE.
Red Man Syndrome — A non-allergic infusion reaction to vancomycin characterized by flushing, itching, rash, and hypotension on the upper body. Prevented by slow infusion over at least 60 minutes.