A nurse is caring for a 45-year-old male client in a medical-surgical unit who has a new prescription for cefazolin.

Exhibits

Which of the following findings should the nurse identify as contraindications to administering cefazolin? (Select all that apply.)

Choice A rationale

Hand hygiene is critical for preventing the spread of MRSA. Washing hands removes any bacteria that may have been picked up during contact with the infected client or surfaces in the room. Proper handwashing technique includes using soap and water or an alcohol-based hand sanitizer for at least 20 seconds.

Choice B rationale

Reusing unsoiled gloves is not recommended because MRSA can persist on surfaces and gloves for prolonged periods. Changing gloves each time entering the room ensures any contamination is not transferred to different areas or patients.

Choice C rationale

Wearing a gown protects the caregiver’s clothing from contamination when assisting with activities like bathing. Gowns act as a barrier to prevent MRSA from contacting the caregiver's skin or clothes and being carried outside the patient’s room.

Choice D rationale

Taking the client outside the room increases the risk of spreading MRSA to others. While a mask may protect against respiratory droplets, it does not prevent the transmission of MRSA via contact with contaminated surfaces or the patient’s skin.

Choice A rationale

Performing neurovascular checks every 2 hours ensures that the nurse can quickly identify signs of compromised circulation or nerve function in the affected extremity. This includes monitoring for changes in color, temperature, sensation, and movement, which are critical for preventing complications such as compartment syndrome.

Choice B rationale

Positioning the fractured arm below the level of the client's heart can increase swelling and impair circulation to the area. It is generally recommended to elevate the arm to reduce edema and promote better blood flow.

Choice C rationale

Immobilizing the client's fingers using a hand splint is not necessary unless there are additional injuries to the hand or fingers. The focus should be on the distal radius fracture and maintaining mobility in the fingers to prevent stiffness and promote circulation.

Choice D rationale

Using a hair dryer to blow hot air into the cast can cause skin burns and damage the cast material. Itching under the cast should be managed with safe methods such as blowing cool air or taking antihistamines if necessary.