Which nursing intervention required a nurse to use standard precaution?

DHS 2018 shift 1st

Nursing Foundation

Medium

Appeared in: DHS 2018 shift 1st

Explanation

Standard precautions are mandatory when there is a risk of contact with blood, body fluids, secretions, excretions, non-intact skin, and mucous membranes.
Emptying a portable wound drainage system involves handling wound exudate, which is a body fluid.
This procedure presents a clear and direct risk of exposure to potentially infectious material.
Therefore, the nurse must use personal protective equipment (PPE), such as gloves, as part of standard precautions to prevent transmission of microorganisms.

Option A: Giving a back rub involves contact with intact skin. There is no anticipated exposure to blood or body fluids.
Option C: Obtaining a blood pressure involves contact with intact skin. Standard precautions are universal and not based on a patient's diagnosis like HIV. The procedure itself does not pose a risk of fluid exposure.
Option D: Assisting with physiotherapy typically involves guiding movements and contact with intact skin, similar to giving a back rub.

Clinical Relevance

Nursing practice connection: Knowing Application of Standard Precautions in Nursing helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Correctly applying standard precautions is fundamental to preventing healthcare-associated infections (HAIs) and protecting both patients and healthcare workers from exposure to infectious agents.
Failure to use standard precautions, especially when handling body fluids, can lead to cross-contamination and occupational exposures to blood-borne pathogens like HIV, HBV, and HCV.
What if? If the patient whose blood pressure was being taken had a bleeding cut under the BP cuff area, the situation would change. The nurse would then need to wear gloves because there is now an anticipated risk of contact with blood, demonstrating that the need for PPE is dictated by the specific situation and risk of exposure, not just the general procedure.

How to Approach the Question

First, understand the core concept: 'Standard precautions' are used for all patients, regardless of their diagnosis, whenever there is a risk of contact with blood or body fluids.
Read the question carefully to identify the key action: which intervention requires these precautions.
Evaluate each option by asking: 'Does this activity involve a risk of touching blood, body fluids, non-intact skin, or mucous membranes?'
Option A (back rub), C (BP check), and D (physiotherapy) primarily involve contact with intact skin. The risk of fluid contact is minimal to none.
Option B (emptying a wound drain) directly involves handling wound drainage, a body fluid. This carries a definite risk.
Select the option with the clear and unavoidable risk of exposure to body fluids as the one requiring standard precautions.

Concept Tested & Keywords

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E6 Nursing Fundamentals Taylor pp. 176-178, 569-571