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: Inspection should be performed first to observe for any visible abnormalities, distention, or movements that could indicate underlying conditions.

Choice B reason: Percussion is used after auscultation to assess the presence of fluid, gas, and to estimate the size of the organs within the abdomen.

Choice C reason: Palpation is typically performed last because it can alter the natural state of the abdomen, potentially causing discomfort and affecting the bowel sounds that are assessed during auscultation.

Choice D reason: Auscultation should be performed before palpation and percussion to avoid altering bowel sounds. It allows the nurse to listen to the natural state of bowel motility and vascular sounds without interference.

A. Airborne B. Droplet C. Protective environment D. Contact

Correct Answer is D

Explanation

Choice A reason: Airborne precautions are used for diseases that are spread through the air over long distances, such as tuberculosis, measles, or chickenpox. VRE is not typically spread through the air.

Choice B reason: Droplet precautions are used for diseases that are spread through large droplets in the air, such as influenza or pertussis. VRE is not spread through droplets but through contact with contaminated surfaces or equipment.

Choice C reason: A protective environment is designed to protect immunocompromised patients from infection and is not typically used for patients with VRE. This type of precaution includes the use of HEPA filters, laminar air flow, and other strategies to maintain a sterile environment.

Choice D reason: Contact precautions are the appropriate measures for a patient with a VRE infection. VRE can be spread from one person to another through contact with contaminated surfaces or equipment or through person-to-person spread, often via contaminated hands. It is not spread through the air by coughing or sneezing. Therefore, contact precautions, including the use of gloves and gowns, are necessary when caring for patients with VRE to prevent the spread of the bacteria.

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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

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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