A nurse just received a client from the emergency department, who presents to the floor with a history of stroke. He is admitted with left-sided weakness. His vital signs are to be monitored every 4 hours. On initial assessment at 0800 the client's blood pressure was noted to be 150/100. What priority action should the nurse do next?

A reason: Wear sterile gloves. Sterile gloves are typically used for invasive procedures or when there is a high risk of infection transmission. While it's important to maintain strict hygiene and infection control when dealing with MRSA, wearing sterile gloves for checking a pulse is not necessary. Sterile gloves are more appropriate for surgical procedures or when directly handling open wounds. In the context of checking a client's pulse, clean gloves are sufficient to prevent the spread of infection.

B reason: Wear an N95 respirator mask. An N95 respirator mask is used to protect against airborne pathogens. MRSA is primarily transmitted through direct contact with contaminated surfaces or person-to-person contact rather than through the air. While respiratory protection is crucial in certain settings, such as for airborne diseases like tuberculosis, it is not required for checking a client's pulse when the primary concern is MRSA. Therefore, this option is not appropriate in this scenario.

C reason: Wear protective eyewear. Protective eyewear is necessary in situations where there is a risk of splashing or exposure to bodily fluids that could enter the eyes. While protective eyewear is an important part of personal protective equipment (PPE), it is not specifically required for checking a client's pulse unless there is an anticipated risk of exposure to bodily fluids. The primary concern with MRSA is skin-to-skin contact or contact with contaminated surfaces, making this option less relevant for the given task.

D reason: Wear clean gloves. Clean gloves are necessary when providing care to any patient, especially one with an infection like MRSA. Wearing clean gloves helps prevent the transmission of bacteria from the healthcare provider to the patient and vice versa. Since MRSA is transmitted via direct contact, clean gloves provide an effective barrier to reduce the risk of spreading the infection. In this scenario, clean gloves are the most appropriate and practical choice for the nurse to use while checking the client's pulse.

A reason:

Plain yogurt is not a clear liquid. It is considered part of a full liquid or soft diet and is not appropriate for the initial postoperative clear liquid diet.

B reason:

Lemon sherbet is not considered a clear liquid. It falls under a full liquid diet and is not suitable for the clear liquid diet phase.

C reason:

Carrot juice, though a liquid, is not clear. It contains pulp and particulates, making it unsuitable for a clear liquid diet.

D reason:

Cranberry juice is appropriate for a clear liquid diet. It is transparent and does not contain any solids, making it suitable for postoperative clients on a clear liquid diet.