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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The diaphragm of the stethoscope is used for high-pitched sounds such as breath sounds, bowel, and normal heart sounds. For the apical pulse, which involves listening to the heart's sounds, the bell of the stethoscope is often recommended, especially for lower-pitched sounds like murmurs.
Choice B reason: Counting the apical pulsations for a full minute is the correct action when assessing the apical pulse, particularly for clients on cardiovascular medications. This ensures accuracy in detecting any irregularities or changes in the heart rate that could be affected by the medications.
Choice C reason: The stethoscope should be placed gently against the client's skin. Pressing too firmly can distort the heart sounds, making it difficult to accurately assess the apical pulse.
Choice D reason: A Doppler device is not typically used for routine assessment of the apical pulse. It is more commonly used when pulses are difficult to palpate or auscultate, such as in cases of peripheral arterial disease.
Correct Answer is C
Explanation
Choice A reason: Offering a beverage is a hospitable gesture but not the first step in taking a health history. The priority is to establish communication and trust.
Choice B reason: Confirming insurance coverage is important but not the initial step in the health history process. The focus should first be on the patient's immediate needs and concerns.
Choice C reason: Establishing a rapport with the patient is the first and most crucial step in taking a health history. It involves creating a comfortable and trusting environment for the patient to share personal health information.
Choice D reason: Asking the patient to disrobe and put on a gown may be necessary for a physical examination but is not the first step in taking a health history. The nurse should first establish a rapport with the patient.
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