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 action because encouraging range of motion can worsen the symptoms and cause more damage to the nerves and blood vessels. Range of motion is the movement of the joints and muscles through their normal extent. Range of motion can help to prevent stiffness, contractures, and muscle atrophy, but it can also increase the swelling and pressure in the affected area, which can impair the circulation and sensation.

Choice B reason: This is not the best action because applying heat to the affected hand can worsen the symptoms and cause more damage to the tissues. Heat is the transfer of thermal energy from a warmer object to a cooler one. Heat can help to relax the muscles, reduce the pain, and increase the blood flow, but it can also increase the inflammation and edema in the affected area, which can compromise the oxygen and nutrient delivery to the tissues.

Choice C reason: This is the best action because removing the cast can decrease the pressure and restore the circulation and sensation to the affected area. A cast is a rigid device that immobilizes and protects a fractured or injured body part. A cast can help to align the bones, prevent displacement, and promote healing, but it can also cause complications, such as compartment syndrome, infection, or nerve damage. Compartment syndrome is a condition where the pressure inside the muscles increases to dangerous levels, causing severe pain, reduced blood flow, and tissue death. The nurse should remove the cast immediately and notify the physician if the client shows signs of compartment syndrome, such as numbness, tingling, pallor, coolness, or swelling.

Choice D reason: This is not the best action because raising the arm above the level of the heart can worsen the symptoms and cause more damage to the nerves and blood vessels. Raising the arm above the level of the heart can help to reduce the swelling and pain in the affected area, but it can also reduce the blood flow and oxygenation to the area, which can lead to ischemia, necrosis, or gangrene. The nurse should elevate the arm at or below the level of the heart and monitor the pulse, color, temperature, and sensation of the fingers.

Choice A reason: A bone fragment has injured the nerve supply in the area is not the best response by the nurse. This may be a possible complication of a fracture, but it does not explain the mechanism of compartment syndrome. Compartment syndrome is a condition where the pressure within a closed space (such as a muscle compartment) exceeds the perfusion pressure and causes ischemia and necrosis of the tissues. A bone fragment may damage the nerve, but it does not cause increased pressure in the compartment.

Choice B reason: An injured artery causes impaired arterial perfusion through the compartment is not the best response by the nurse. This may be a possible cause of compartment syndrome, but it is not the most common one. Compartment syndrome is more often caused by venous obstruction than arterial obstruction. An injured artery may reduce the blood flow to the compartment, but it does not cause increased pressure in the compartment.

Choice C reason: Bleeding and swelling cause increased pressure in an area that cannot expand is the best response by the nurse. This is the most common cause of compartment syndrome and explains the pathophysiology of the condition. Bleeding and swelling are the result of inflammation and tissue injury that occur after a fracture. They increase the volume of fluid in the compartment, which cannot expand due to the rigid fascia that surrounds it. This leads to increased pressure in the compartment, which compresses the blood vessels, nerves, and muscles and causes ischemia and necrosis of the tissues.

Choice D reason: The fascia expands with injury, causing pressure on underlying nerves and muscles is not the best response by the nurse. This is not a correct statement, as the fascia does not expand with injury. The fascia is a tough connective tissue that encloses the muscle compartments and limits their expansion. The fascia is part of the problem, not the cause, of compartment syndrome. The fascia prevents the compartment from accommodating the increased volume of fluid and causes increased pressure in the compartment.