A client has been placed on Contact Precautions. The client’s family is very afraid to visit. What is the best action for the nurse to take?

Choice A rationale:
Tolerance to the opiate medication is developing. This is the most likely explanation for why the client's pain is no longer being controlled by the same dose of medication. Tolerance is a physiological adaptation that occurs with repeated exposure to opioids, leading to a decrease in their effectiveness over time. This means that the client's body is becoming less responsive to the medication, and a higher dose is needed to achieve the same level of pain relief.
Choice B rationale:
There is likely a history of addiction. While it is possible that the client has a history of addiction, this is not the most likely explanation for why the medication is no longer controlling the pain. Addiction is a complex condition that is characterized by compulsive drug seeking and use, despite negative consequences. It is not simply a matter of tolerance developing.
Choice C rationale:
The client is opiate naive. This means that the client has not previously been exposed to opioids. While opiate-naive clients may be more sensitive to the effects of opioids, they are also more likely to experience side effects, such as nausea and vomiting. The fact that the client has been receiving the same dose of medication for 2 days without experiencing side effects suggests that they are not opiate naive.
Choice D rationale:
Physical dependence. Physical dependence is a state of adaptation that occurs with repeated exposure to opioids, leading to withdrawal symptoms if the medication is abruptly stopped. However, physical dependence does not necessarily mean that the medication is no longer effective in controlling pain.

Choice A rationale:
Wearing a respirator when handling urine output is not routinely recommended for MRSA infections. While airborne transmission of MRSA is possible, it is primarily spread through direct contact with infected skin or surfaces. Respirators are typically reserved for situations where there is a high risk of aerosolization, such as during certain medical procedures.
The use of a respirator can be cumbersome and uncomfortable, and it may not provide significant additional protection in this context.

It's important to prioritize hand hygiene and contact precautions over respirator use for routine care of patients with MRSA infections.
Choice B rationale:
Limiting visitors strictly to immediate family members only is not necessary for MRSA infection control. Visitors can be educated on proper hand hygiene and contact precautions to minimize the risk of transmission.
Restricting visitors can have negative psychosocial impacts on the patient, such as isolation and decreased social support. It's important to balance infection control measures with the patient's overall well-being.
Choice C rationale:
Washing hands only after removing gloves post-care is inadequate for MRSA infection control. Hands should be washed thoroughly with soap and water or an alcohol-based hand sanitizer:
Before and after entering the patient's room
Before and after any contact with the patient or their surroundings After removing gloves
After using the toilet Before eating or drinking.

Choice D rationale:
Vancomycin is an antibiotic that is effective against MRSA infections. It is often the first-line treatment for these infections.
Preparing to administer vancomycin as prescribed by the healthcare provider is the most appropriate action to take to address the patient's MRSA infection.
Prompt initiation of appropriate antibiotic therapy is essential to controlling the infection and preventing complications.