A nurse is caring for a 45-year-old patient with a confirmed MRSA skin infection on the lower leg. Which nursing intervention should be the highest priority to prevent transmission to other patients and healthcare workers?
A 45-year-old patient has been admitted with a large, purulent wound on the lower leg that has tested positive for MRSA. The patient is ambulatory and frequently leaves the room to walk in the hallways.
1Implement contact precautions with dedicated equipment and proper hand hygiene protocols✓ 정답
2Administer prescribed vancomycin intravenously as ordered
3Perform wound irrigation with normal saline twice daily
4Educate the patient about the importance of completing antibiotic therapy
해설
Contact precautions are the highest priority to prevent MRSA transmission in healthcare settings. Other interventions are important but secondary to infection control.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing action for a patient with a confirmed Methicillin-resistant Staphylococcus aureus (MRSA) infection. The core theme is Infection Control and Standard Precautions. MRSA is a multi-drug resistant organism (MDRO) spread primarily through direct contact with the infected site or contaminated items. The scenario highlights a key risk factor: the patient is ambulatory and frequently leaves the room, increasing the potential for environmental contamination and transmission to others. In nursing, the principle of Key Point! "Safety First" means preventing harm to other patients and staff is the top priority, which aligns with the nursing process where assessment and immediate risk mitigation come before definitive treatment or education.
Answer Rationale: Option 1 is correct because it directly addresses the immediate risk of transmission. Contact Precautions involve placing the patient in a private room (or cohorting), using gowns and gloves for all contact with the patient or their environment, and dedicating equipment (e.g., stethoscope, blood pressure cuff) to that room. Combined with rigorous Hand hygiene (the single most effective infection control measure), this intervention forms a barrier to stop the chain of infection. This is the highest priority action upon confirmation of MRSA to protect public health within the facility.
Distractor Analysis:
Watch out for confusion! Option 2 (Administering vancomycin) is a crucial treatment intervention but is not the highest priority for preventing transmission. The antibiotic treats the patient's infection but does not stop the bacteria from spreading to others. Treatment is important but follows containment.
Option 3 (Wound irrigation) is a standard wound care procedure. While it promotes healing and removes exudate (which contains bacteria), performing it without first establishing proper isolation precautions could expose healthcare workers and the environment to MRSA.
Option 4 (Patient education) is an essential component of care to prevent recurrence and antibiotic resistance, but it is a long-term and collaborative intervention. It does not address the acute, immediate risk of transmission to others in the healthcare setting.
Related Concepts: This question integrates fundamentals of medical-surgical nursing, microbiology, and public health. Understanding the modes of transmission for different pathogens is critical. For example, MRSA requires Contact Precautions, while tuberculosis requires Airborne Precautions (N95 respirator, negative pressure room), and influenza requires Droplet Precautions (surgical mask). The NCLEX often tests the ability to prioritize actions based on immediate patient or public safety needs.
Concept Summary
Concept
Description
Application in this Scenario
Contact Precautions
Used for pathogens spread by direct or indirect contact (e.g., MRSA, VRE, C. diff). Requires gloves & gown, dedicated equipment, private room.
Highest priority to isolate the MRSA from other patients and staff.
Transmission-Based Precautions
Additional measures beyond Standard Precautions. Includes Contact, Droplet, and Airborne.
Determines the specific type of isolation needed based on the pathogen.
Chain of Infection
Infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host.
Priority interventions aim to break the mode of transmission (contact) and protect susceptible hosts (other patients).
Hand Hygiene
Core component of Standard Precautions.
Essential before and after patient contact, even when wearing gloves.
Side-by-Side Comparison!
Type of Precaution
Pathogens/Examples
Key PPE & Requirements
Room Type
Contact
MRSA, VRE, RSV, C. difficile, major wound infections
Gloves & Gown (for contact with patient/environment)
Private room or cohort
Droplet
Influenza, pertussis, meningococcal meningitis, COVID-19 (per some guidelines)
Surgical Mask (within 3-6 feet of patient), Eye protection if splash risk
Fit-tested N95 respirator or PAPR (Powered Air-Purifying Respirator)
Negative pressure room (AIIR); door closed
Anatomy, Physiology & Pharmacology PointsMicrobiology: MRSA is a strain of Staphylococcus aureus that has acquired resistance to beta-lactam antibiotics (methicillin, oxacillin, penicillin). It produces an altered penicillin-binding protein (PBP2a) that antibiotics cannot bind to effectively.
Pharmacology - Vancomycin: A glycopeptide antibiotic that is often the drug of choice for serious MRSA infections. Key nursing considerations: Monitor for Red Man Syndrome (flushing, rash, hypotension during infusion – managed by slowing infusion rate), nephrotoxicity, and ototoxicity. Trough levels are monitored (Normal Value: typically 10-20 mcg/mL for most infections).
Memory Tips
MRSA Memory Hook: "Meticillin-Resistant = Must Restrict Contact!"
Precaution Priorities: Think "Air comes before Droplet comes before Contact" for the strength of isolation, but for priority in a new diagnosis, initiating the correct precaution is always urgent.
Hand Hygiene Rule: "In, Out, Before, After" – Perform hand hygiene when entering and leaving a patient's room, before and after any procedure or patient contact.
High-Frequency NCLEX Topics
Infection control is a High Yield area. The NCLEX loves to test:
1. Priority Setting: Choosing infection control actions over other correct interventions.
2. PPE Selection: Knowing exactly what to wear for which type of precaution.
3. Sequence of Donning/Doffing PPE: Gown first, then mask, then goggles, then gloves for donning; reverse order for doffing, with hand hygiene at key steps.
4. Patient Education on Isolation: Teaching patients why they are in isolation and how they can cooperate (e.g., staying in their room).
Watch Out for Question Variations!
From Symptom to Action: "A patient with diarrhea is suspected of having C. difficile. Which action should the nurse take first?" (Answer: Place on Contact Precautions and obtain stool specimen).
Changing the Pathogen: "A patient with active pulmonary TB is admitted. What is the priority intervention?" (Answer: Place in an Airborne Infection Isolation Room (AIIR) and have staff wear N95 respirators).
Focus on Equipment: "For a patient on Contact Precautions for MRSA, which item can leave the room?" (Answer: Only essential items that can be properly disinfected; dedicated equipment should stay).
Nursing Clinical Practice GuideClinical Scenario: You are the charge nurse on a medical-surgical unit. A new admission, Mr. Jones, has a large, draining leg wound. The lab calls to report the wound culture is positive for MRSA. Mr. Jones is currently walking in the hallway with his IV pole.
Nursing Intervention Strategy:
1. Immediate Action (Priority): Politely ask Mr. Jones to return to his room. Explain briefly, "Mr. Jones, for everyone's safety, we need you to stay in your room for now. I'll explain why in just a moment." Immediately place a Contact Precautions sign on the door.
2. Set Up the Environment: Ensure a gown and glove supply is outside the room. Bring in a dedicated stethoscope, blood pressure cuff, and thermometer for use only in that room. Label them clearly.
3. Patient Education: Once precautions are initiated, educate Mr. Jones. Use clear, non-judgmental language: "The test on your wound showed a specific germ that can spread easily by touch. To protect other patients and your family visitors, we need to use these gowns and gloves. It's also very important that you stay in your room unless we need to take you for a test. You can walk inside your room for exercise."
4. Coordinate Care: Inform all team members (CNAs, physicians, physical therapy) about the precautions. Document the initiation of Contact Precautions in the chart.
Patient Safety and Precautions:
Hand Hygiene is Non-Negotiable: Perform with alcohol-based rub or soap and water immediately after removing gloves and gown, before leaving the room.
Environmental Cleaning: The room requires daily and terminal cleaning with a disinfectant effective against MRSA. High-touch surfaces (bed rails, call button, IV pump) are critical.
Visitors: Educate visitors on how to don PPE. They should also limit movement around the unit.
Nursing Procedure & Medication FlowProcedure for Donning PPE (Contact Precautions):
1. Perform hand hygiene.
2. Put on the gown (tie at neck and waist).
3. Put on mask or respirator (if needed for standard or other precautions).
4. Put on eye protection (if needed).
5. Put on gloves (extend cuffs over gown sleeves).
Procedure for Doffing PPE (Contact Precautions):
1. Remove gloves (peel off, turning inside out).
2. Perform hand hygiene.
3. Remove gown (unfasten ties, peel off away from body, roll into a bundle).
4. Perform hand hygiene.
5. Remove eye protection (handle by ear pieces).
6. Remove mask (handle by ties/ear loops).
7. Perform hand hygiene.
Vancomycin Administration:
- Check order and verify allergy status.
- Infusion Rate: Administer over at least 60 minutes (often 60-120 mins) to prevent Red Man Syndrome. Use an IV pump.
- Monitoring: Observe closely during first infusion for flushing, rash, itching, hypotension. Have diphenhydramine (Benadryl) available per protocol.
- Lab Monitoring: Ensure trough levels are drawn correctly (just before the next dose, when the drug is at its lowest concentration).
A Word from Your Senior Nurse
"In the real world, infection prevention is a team sport and you are the quarterback on the unit. That moment when you get a positive MRSA result and see the patient walking down the hall – that's when your training kicks in. Your calm, firm action to contain the situation protects every other patient on the floor, including the immunocompromised ones in the next room. Never feel awkward about enforcing precautions; it's a sign of a competent, caring nurse. On the NCLEX, they are testing this exact judgment: can you see the bigger picture of public health and act to secure the environment before diving into the details of treatment? Master this mindset."
Contact Precautions — Infection control measures used for pathogens spread by direct or indirect contact. Includes use of gloves and gown, dedicated patient equipment, and a private room or cohorting.
MRSA (Methicillin-resistant Staphylococcus aureus) — A strain of Staphylococcus aureus bacteria resistant to many common beta-lactam antibiotics (e.g., methicillin, oxacillin). It is a major cause of healthcare-associated infections (HAIs) and community-acquired infections.
Hand Hygiene — The most critical measure to prevent the transmission of pathogens. Includes washing hands with soap and water or using an alcohol-based hand rub. Must be performed before and after patient contact, after contact with body fluids, and after removing gloves.
Standard Precautions — The foundation of infection prevention, applied to all patient care regardless of diagnosis. Assumes all blood, body fluids, secretions, non-intact skin, and mucous membranes may be infectious. Includes hand hygiene, use of PPE, safe injection practices, and environmental controls.
Transmission-Based Precautions — Additional precautions used alongside Standard Precautions for patients known or suspected to be infected with highly transmissible pathogens. They are categorized as Contact, Droplet, or Airborne Precautions based on the pathogen's mode of transmission.