The home health nurse assesses an older adult client and observes possible signs of abuse.
Which resource should the nurse use to guide their decision regarding reporting these suspicions?

Answer and explanation

The correct answer is Choices B, C, D, and E.

Choice A rationale

Areas with negative-pressure airflow are typically used in healthcare settings to prevent the spread of airborne pathogens, not bloodborne pathogens.

Choice B rationale

Puncture-resistant sharps containers are a crucial part of an exposure control plan for bloodborne pathogens. They provide a safe way to dispose of sharps, reducing the risk of needlestick injuries.

Choice C rationale

Needleless medication delivery systems can significantly reduce the risk of needlestick injuries, thereby reducing the risk of exposure to bloodborne pathogens.

Choice D rationale

A vaccination schedule for Hepatitis B is an important part of an exposure control plan. Hepatitis B is a bloodborne pathogen, and vaccination is an effective way to prevent infection.

Choice E rationale

Personal protective equipment (PPE) is a key component of an exposure control plan. PPE such as gloves, gowns, and face shields can provide a barrier between the healthcare worker and potentially infectious material.

Answer and explanation

The correct answer is Choice B.

Choice A rationale

Rechecking the client’s vital signs in 30 minutes may not be the most appropriate action in this situation. The client is showing signs of possible complications such as infection (elevated

temperature, malaise) and referred pain in the shoulder, which could indicate diaphragmatic irritation. These symptoms, along with the client’s recent surgery, suggest that immediate medical attention may be necessary.

Choice B rationale

Having the client transported via ambulance to the hospital is the most appropriate action. The client’s symptoms suggest possible complications that require immediate medical attention.

Abdominal tenderness and shoulder pain could indicate a serious condition such as a perforation or infection. The elevated heart rate and low blood pressure could suggest sepsis or shock. Immediate medical evaluation and treatment are necessary.

Choice C rationale

Determining the client’s current oxygen saturation rate is important, but it is not the most immediate need. While this information could provide additional data about the client’s condition, it does not address the potential seriousness of the client’s symptoms. The client needs immediate medical attention.

Choice D rationale

Instructing the client to drive to the hospital for admission is not the best choice. Given the client’s symptoms and recent surgery, it would be safer for the client to be transported by ambulance. This would ensure that the client receives immediate medical attention and that the client’s condition can be monitored during transport.