A nurse is assisting in the care of a client who is on isolation for an infection with vancomycin-resistant enterococcus (VRE). Which of the following actions should the nurse take to prevent the spread of infection?

A. The nurse handled the sterile gauze with clean gloves on: Handling sterile gauze with clean, non-sterile gloves contaminates the gauze and compromises the sterile field. Sterile gloves or sterile instruments must be used to maintain sterility.

B. The nurse opened the package of gauze toward their body: Opening a sterile package toward the body increases the risk of contaminating the sterile field. The first flap should always be opened away from the body to maintain proper sterile technique.

C. The nurse placed a bottle of saline on the sterile field: Placing a non-sterile item, such as an unsterilized saline bottle, onto a sterile field contaminates the entire field. Only sterile items should touch the sterile field.

D. The nurse kept their hands above the waist during the dressing change: Maintaining hands above the waist is crucial in sterile technique. Anything held below waist level is considered contaminated, so this action shows proper understanding of maintaining sterility.

A. Place the client on bedrest: While limiting the client’s activity is important to reduce oxygen demand, it is not the first priority. Immediate actions should focus on improving oxygenation and reducing respiratory distress.

B. Obtain the client's ABG levels: Although obtaining arterial blood gases provides valuable information about oxygenation and acid-base balance, it does not address the immediate need to relieve the client's breathing difficulty and hypoxia.

C. Elevate the head of the client's bed: Elevating the head of the bed promotes lung expansion and improves oxygenation, making it the first action to reduce dyspnea and ease the client’s breathing. It is a simple, quick intervention that can stabilize the client while further assessments are conducted.

D. Prepare the client for a ventilation-perfusion scan: A V/Q scan may be indicated to diagnose conditions like pulmonary embolism, but it is a diagnostic step that follows stabilization. Immediate efforts must first focus on ensuring adequate oxygenation and respiratory support.