A nurse is caring for a client who has methicillinresistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse prepares to enter the room to check the client's pulse. What personal protective equipment (PPE) should the nurse wear?

Choice A reason: This is not the best intervention because it is timeconsuming and may not be feasible in some situations. Writing down the message can also be impersonal and may not convey the tone or emotion of the speaker. The nurse should use verbal communication as much as possible and supplement it with nonverbal cues, such as gestures, facial expressions, and eye contact.

Choice B reason: This is an incorrect intervention because it can be annoying and ineffective. Talking loudly in the impaired ear can cause discomfort and distortion of the sound. It can also damage the remaining hearing in the ear. The nurse should not shout or raise their voice, but rather speak at a normal volume and enunciate clearly.

Choice C reason: This is the best intervention because it enhances the quality and clarity of the verbal message. Speaking slowly and clearly while facing the client allows the client to see the nurse's mouth movements and facial expressions, which can help them understand the words and the meaning. The nurse should also avoid covering their mouth or chewing gum while speaking.

Choice D reason: This is not the best intervention because it can be inconvenient and impractical. Talking in a regular voice in the good ear may require the nurse to move around the client or position themselves in a certain way. It can also make the client feel isolated or singled out. The nurse should try to communicate with the client in a way that is comfortable and respectful for both parties.

Choice A reason: Cleansing the skin routinely after soiling occurs is an effective intervention to prevent skin injury. This is because soiling from urine, feces, sweat, or wound drainage can irritate the skin and cause inflammation, infection, or breakdown. The nurse should use a gentle cleanser and warm water and pat the skin dry. The nurse should also avoid using harsh chemicals, alcohol, or perfumes on the skin.

Choice B reason: Applying moisturizer to dry areas of skin is an effective intervention to prevent skin injury. This is because dry skin is more prone to cracking, peeling, or tearing. The nurse should use a hypoallergenic moisturizer and apply it to the skin after cleansing and drying. The nurse should also avoid using products that contain alcohol, fragrances, or dyes on the skin.

Choice C reason: Using a Hoyer lift for all transfers is an effective intervention to prevent skin injury. This is because a Hoyer lift is a mechanical device that helps to lift and move the client safely and comfortably. It reduces the friction and shear on the skin by lifting the client off the bed surface and avoiding any sliding or dragging. It also prevents the nurse from injuring themselves by lifting the client manually.

Choice D reason: Massaging the client’s reddened shoulders and heels is not an effective intervention to prevent skin injury. In fact, this may worsen the skin injury by increasing the pressure and damage to the tissues. The nurse should avoid massaging any areas that are reddened, swollen, or blistered, as these are signs of pressure ulcers. The nurse should instead relieve the pressure by repositioning the client or using pressurerelieving devices, such as pillows, foam pads, or air mattresses.

Choice E reason: Repositioning the client once per shift is not an effective intervention to prevent skin injury. This is because repositioning the client once per shift is not frequent enough to prevent the development of pressure ulcers. Pressure ulcers are caused by prolonged pressure on the skin that reduces the blood flow and oxygen to the tissues. The nurse should reposition the client at least every 2 hours or more often if needed, depending on the client's condition and risk factors.