A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take to help prevent an incisional infection?

Clean the incision with soap and water.

Perform hand hygiene prior to dressing changes.

Initiate protective isolation.

Allow the wound to air periodically.

Answer and Explanation

The Correct Answer is B

Choice A reason: Cleaning the incision with soap and water is not typically recommended as it can disrupt the healing process and may lead to irritation or infection. The incision should be kept clean and dry, and any cleaning should be done according to the surgeon's instructions.

Choice B reason: Performing hand hygiene before dressing changes is essential in preventing incisional infections. Hand hygiene is one of the most effective ways to prevent the spread of infections, including those at surgical sites.

Choice C reason: Protective isolation is used for immunocompromised patients to protect them from infections, not typically for postoperative patients unless they are at high risk for infection due to other conditions.

Choice D reason: Allowing the wound to air can be part of the healing process, but it must be done carefully and under the guidance of healthcare professionals to ensure that the wound is protected from contamination.

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Correct Answer is D

Explanation

Choice A reason: Protective precautions are used to shield immunocompromised patients from infections, not typically for patients with meningococcal pneumonia.

Choice B reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. Meningococcal pneumonia is not primarily spread this way.

Choice C reason: Airborne precautions are for diseases that are spread through the air over long distances, such as tuberculosis. Meningococcal pneumonia is not spread in this manner.

Choice D reason: Droplet precautions are recommended for meningococcal pneumonia. This infection can be spread through droplets from the respiratory tract when the infected person coughs or sneezes. Therefore, droplet precautions, including the use of masks, are necessary to prevent the spread of this infection.

A. Initiate humidification therapy. B. Encourage the client to cough and deep breathe. C. Increase the client's oral fluid intake. D. Raise the head of the bed.

Correct Answer is D

Explanation

Choice A reason: Initiating humidification therapy can be beneficial for a client with pneumonia. Humidified air can help loosen respiratory secretions, making them easier to expectorate. However, while this intervention is helpful, it is not typically the first action a nurse should take. The priority is to address the client's immediate need for adequate oxygenation and ventilation.

Choice B reason: Encouraging the client to cough and perform deep breathing exercises is an essential part of care for patients with pneumonia. These actions help to clear mucus from the lungs and improve ventilation. Deep breathing helps to fully expand the alveoli, which can be compromised in pneumonia, and coughing helps to expel secretions that may be blocking the airways. However, this is not the most immediate action when the oxygen saturation is borderline normal.

Choice C reason: Increasing the client's oral fluid intake is important in the management of pneumonia. Adequate hydration thins respiratory secretions, making them easier to clear. It also supports overall bodily functions, which can be taxed during illness. Nonetheless, this intervention is not the most critical initial step in managing a client's immediate respiratory needs.

Choice D reason: Raising the head of the bed is the correct and immediate action to take for a client with pneumonia and an oxygen saturation of 88%. This position helps to improve chest expansion, promotes better lung aeration, and facilitates easier breathing. It also reduces the risk of aspiration, which is particularly important in clients with pneumonia. Elevating the head of the bed is a simple yet effective way to enhance oxygenation and should be the first step taken.

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A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take to help prevent an incisional infection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client who has meningococcal pneumonia. Which of the following isolation precautions should the nurse initiate?

Correct Answer is D

Explanation

A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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