Which term should the nurse use to document a raised, fluid-filled lesion smaller than 1 centimeter?

• Place the client in a private room.
  • Essential: Placing the client in a private room helps prevent the spread of MRSA to other patients and reduces the risk of transmission.
• Administer intravenous vancomycin.
• • Essential: Vancomycin is an appropriate antibiotic choice for treating MRSA infections, and administering it intravenously allows for effective delivery of the medication to combat the infection.
• Wear a cover gown when caring for the client.
  • Essential: Wearing a cover gown provides an additional barrier of protection against potential contact with the client's infected wound and helps prevent transmission of MRSA to healthcare workers and other patients.
• Restrict fluid intake.
• • Contraindicated: Restricting fluid intake is not indicated in this scenario. Adequate hydration is essential for supporting the body's immune response and maintaining organ function, especially in the presence of fever and infection.
• Initiate supplemental oxygen.
• • Nonessential: Supplemental oxygen is not indicated based on the client's oxygen saturation of 96% on room air. Oxygen supplementation is typically reserved for clients who are hypoxic or experiencing respiratory distress, which is not the case here.

A. "All patients are presumed infectious.": This statement reflects the principle of universal precautions, which assumes that all patients may potentially transmit infectious agents, regardless of their diagnosis or symptoms. It emphasizes the importance of implementing infection prevention practices for every patient encounter to minimize the risk of transmission.
B. "Isolation is not required for most diseases.": While isolation precautions may not be required for all diseases, the statement does not fully capture the concept of universal precautions.
C. "Patients with a known infection are placed in isolation only when they are admitted.": This statement is not accurate as patients with known infections should be placed in isolation as soon as possible to prevent the spread of infection to others.
D. "Patients are not considered infectious until confirmed so by the laboratory.": Waiting for laboratory confirmation before implementing infection control measures could lead to delays in preventing transmission, as patients may be infectious before laboratory results are available.