A nurse is caring for a client who is receiving intravenous fluids. The nurse notes the client's skin around their peripheral IV site is taut and edematous. Which of the following complications is the client experiencing?

A. Place the client in a room with negative-pressure airflow: Negative-pressure airflow is used for airborne precautions. MRSA requires contact precautions, which include placing the client in a private room or a room with others who have the same infection.

B. Ensure visitors use a surgical mask when they enter the client's room: Surgical masks are not required for MRSA unless there is a respiratory complication. For MRSA, visitors should use gloves and gowns for contact precautions, but a mask is not necessary.

C. Remove isolation gown before removing gloves: The gown should be removed after the gloves to prevent contamination. The gloves should be removed first to avoid touching any surfaces with contaminated hands, and then the gown can be safely removed.

D. Use designated equipment that stays in the client's room: To prevent the spread of MRSA, designated equipment (such as blood pressure cuffs, stethoscopes, and thermometers) should stay in the client's room. This minimizes risk of cross-contamination and ensures infection control.

B. Don clean gloves: The nurse should first don clean gloves to ensure proper hygiene and to reduce the risk of infection during the procedure. This protects both the client and the nurse from any potential contamination.

E. Attach the syringe to the balloon injection port: After gloves are on, the next step is to attach the syringe to the balloon injection port of the catheter. This is the part where sterile fluid (usually saline) was used to inflate the balloon that keeps the catheter in place.

C. Withdraw the solution from the balloon: Once the syringe is attached, the nurse slowly withdraws the fluid from the balloon. This is necessary to deflate the balloon, which allows the catheter to be removed easily and without causing injury to the urethral canal.

A. Slowly pull the catheter out of urethral canal: After the balloon is deflated, the nurse gently and slowly pulls the catheter out of the urethral canal. This should be done carefully to avoid causing trauma to the urethra and surrounding tissues. The catheter should be removed in a smooth, controlled motion.

D. Dry the perineal area: After the catheter is removed, the nurse should clean and dry the perineal area to ensure hygiene. This step helps prevent skin irritation and infection after the catheter removal, ensuring that the area is properly cared for and free of moisture.