# A nurse is caring for multiple patients on a medical-surgical unit. Which action by the nurse demonstrates the most appropriate application of standard precautions?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541829  
> language: ko  
> subject: Infectious Diseases

## 문제

A nurse is caring for multiple patients on a medical-surgical unit. Which action by the nurse demonstrates the most appropriate application of standard precautions?

## 보기

1. Wearing gloves only when caring for patients with known infectious diseases
2. Using contact precautions for all patients regardless of their diagnosis
3. Treating all patients' blood and body fluids as potentially infectious **✔ 정답**
4. Applying airborne precautions when entering any patient room

**정답: 3**

## 해설

Standard precautions require treating all patients' blood and body fluids as potentially infectious, regardless of diagnosis. This universal approach prevents transmission from asymptomatic or undiagnosed infections. Other options incorrectly limit precautions based on known infections or overapply specific precautions.

## 심화 해설

Core Principle of Standard Precautions

The foundation of standard precautions is the assumption that all patients may harbor transmissible pathogens, regardless of their diagnosis, perceived risk, or known infection status. This principle is designed to protect both healthcare workers and patients from the bidirectional transmission of microorganisms found in blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes. The most appropriate application is therefore to treat all blood and body fluids from every patient as potentially infectious .

Why the Other Options Are Incorrect

- Option 1 (Wearing gloves only when caring for patients with known infectious diseases) is a dangerous violation of standard precautions. It relies on a known diagnosis, which is often unavailable or delayed. Many patients in a medical-surgical unit may be colonized with multidrug-resistant organisms or be in the prodromal or asymptomatic phase of a viral infection without their knowledge. A study on nursing students demonstrated that clinical training and education are essential to shift this mindset, improving compliance with the principle that gloves are required for any anticipated contact with blood or body fluids, not just for known infections .

- Option 2 (Using contact precautions for all patients regardless of their diagnosis) reflects a misunderstanding of transmission-based precautions. Contact precautions are a second-tier set of practices applied in addition to standard precautions for patients with known or suspected infections that are spread by direct or indirect contact (e.g., C. difficile, MRSA). Applying them universally is not only resource-intensive and unnecessary but also blurs the critical distinction between the baseline level of safety (standard precautions) and the escalated measures for specific, highly transmissible pathogens .

- Option 4 (Applying airborne precautions when entering any patient room) is incorrect for the same conceptual reason as Option 2. Airborne precautions require specialized engineering controls (e.g., negative pressure room) and personal protective equipment (e.g., fit-tested N95 respirator) and are reserved for pathogens that remain infectious over long distances, such as Mycobacterium tuberculosis, rubeola virus, and varicella-zoster virus. Routine application to all patients would paralyze workflow and is not supported by evidence or guidelines .

Clinical Integration and Evidence

The rationale for Option 3 is directly supported by research evaluating educational interventions aimed at improving nurses' knowledge and compliance. A quasi-experimental study found that multifaceted interventions based on education and recognition significantly enhanced nurses' compliance with standard precautions, reinforcing the core concept that all patient encounters carry a baseline infection risk . Similarly, research using educational technology with nursing students focused on shifting attitudes and practices to align with the universal application of standard precautions, moving away from a selective, diagnosis-driven approach . The high prevalence of healthcare-associated infections underscores why this non-selective, universal precaution mindset is the cornerstone of safe nursing practice on any medical-surgical unit .

## 임상 시나리오

Standard Precautions: Clinical ApplicationUniversal application for all patient encounters
The core principle of Standard Precautions is to treat all blood and body fluids from every patient as potentially infectious, irrespective of their diagnosis.

Perform hand hygiene before and after every patient contact, and after removing gloves. Use personal protective equipment (PPE) such as gloves, gowns, masks, and eye protection based on the anticipated exposure risk, not the patient's known infection status.

CautionDo not reserve glove use only for patients with known infections. Many pathogens are transmissible during asymptomatic or prodromal phases. Relying on a diagnosis creates a false sense of security and increases exposure risk.

## 핵심 개념

- **Standard Precautions** — The minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status, based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents.
- **Transmission-Based Precautions** — The second tier of basic infection control, used in addition to standard precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission (Contact, Droplet, Airborne).

## 같은 주제 문제

- [A nurse is caring for a patient with suspected methicillin-resistant Staphylococcus aureus…](https://mymerci.kr/pages/nclex_q.php?qn_id=541828)

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