A nurse is collecting data from a newborn who has fetal alcohol syndrome. Which of the following manifestations should the nurse (Select all that apply.)

A) "Ensure that the negative air pressure is active for the client’s room.": Negative air pressure is used for airborne precautions, such as in the case of tuberculosis or other airborne infections. MRSA is primarily spread through direct contact, not airborne transmission, so negative air pressure is not necessary in this situation.

B) "Place the client in a room with a high-efficiency particulate air (HEPA) filter.": A HEPA filter is used for airborne precautions to filter out airborne particles like those found in diseases such as tuberculosis or measles. Since MRSA is transmitted through direct contact and not airborne particles, placing the client in a room with a HEPA filter is not necessary.

C) "Have the client wear a mask when they are out of their room.": MRSA is typically spread by direct contact with infected wounds, bodily fluids, or contaminated surfaces. It is not transmitted via respiratory droplets, so there is no need for the client to wear a mask when they leave their room. The focus should be on contact precautions rather than respiratory precautions.

D) "Don gloves prior to assisting the client with brushing their teeth.": MRSA is a contact-borne infection, so it is essential to use proper personal protective equipment, such as gloves, when coming into direct contact with the client or any of their bodily fluids or contaminated items (such as toothbrushes). Donning gloves prior to assisting with brushing their teeth ensures that the nurse avoids direct contact with potential sources of infection. This is an important measure in preventing the spread of MRSA.

A) "Wash the site daily with warm water": The nurse should instruct the client to wash the radiation treatment site gently with warm water and mild soap (without scrubbing or using harsh soaps). This helps to cleanse the skin without irritating it. Keeping the skin clean can help prevent infection and minimize irritation during the course of radiation therapy. It's important not to use hot water or harsh chemicals, as the skin in the treated area can be sensitive.

B) "Wash skin markings off after each treatment": Skin markings are placed on the client's skin by the radiation oncologist to ensure the radiation is targeted precisely. These marks should not be washed off, as they are necessary for the planning and delivery of radiation. Washing off the marks could affect the accuracy of the treatment.

C) "Apply lotion to the site after treatment": While it may seem like a good idea to apply lotion to moisturize the skin, clients undergoing radiation therapy should avoid applying any lotions, creams, or ointments to the radiation site unless specifically prescribed by their healthcare provider. Some lotions or creams may contain chemicals that could irritate the skin further or interfere with the radiation treatment. Only approved products should be used.

D) "Cover the site with a transparent dressing": Covering the radiation treatment site with a transparent dressing is typically not recommended unless the client has an open wound or is instructed to do so by the healthcare provider. The treated skin should be left exposed to air to promote healing unless advised otherwise. Covering the site could trap moisture, leading to skin irritation or infection.