While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA) laboratory result, which action is the most important for the nurse to take?
Explanation & Rationale
A. Ensure the client's environment is properly cleaned and disinfected is important, but the priority action is to prevent the spread of MRSA, which is highly contagious. Contact precautions should be initiated immediately to reduce the risk of transmission to others, including healthcare staff and visitors. B. Reapply sterile non-adhesive dressing is necessary for wound care, but it is not the most important action in this scenario. Ensuring the appropriate precautions are taken to prevent the spread of MRSA is the priority. C. Initiate contact precautions is the most important action. MRSA is a highly contagious bacterial infection that can spread easily through contact with contaminated surfaces or individuals. By initiating contact precautions, the nurse helps to protect other patients, staff, and visitors from exposure to MRSA. D. Teach family members how to prevent transmission of infection is important but should be done after the immediate infection control measures, such as initiating contact precautions, have been implemented. Family education can occur once the proper isolation procedures are in place.