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 C
Explanation
Choice A reason: While providing a newborn's first bath, there is minimal risk of exposure to infectious fluids that would necessitate eye protection. However, standard precautions should always be followed.
Choice B reason: When giving personal care to an infant who is HIV-positive, standard precautions should be followed, which includes wearing gloves. Eye protection is not typically required unless there is a risk of splashing bodily fluids.
Choice C reason: Suctioning secretions from a child's newly placed tracheostomy tube requires eye protection because there is a high risk of secretions being expelled forcefully, which could contact the mucous membranes of the eyes.
Choice D reason: Withdrawing cord blood from a neonate generally does not require eye protection unless there is a risk of blood splatter. Standard precautions, including the use of gloves, should be sufficient.
Choice E reason: Transporting a cerebrospinal fluid specimen to the laboratory does not require the nurse to wear eye protection. However, the nurse should ensure that the specimen is sealed properly to prevent any leaks.
Correct Answer is D
Explanation
Choice A reason: The FACES pain scale is commonly used for children who are able to select a face that best describes their pain. However, this scale is not suitable for a 6-month-old infant post-myringotomy, as infants of this age cannot verbally communicate or reliably choose a face to represent their pain level.
Choice B reason: The Visual Analog Scale (VAS) is typically used for older children and adults who can understand and indicate their level of pain by marking a point on a line. This scale is not appropriate for infants due to their developmental stage and inability to communicate or understand the concept of the scale.
Choice C reason: The Oucher pain scale includes both a photographic scale with pictures of children's faces showing different levels of pain and a numerical scale. While it is designed for children aged 3 to 12 years, it is not suitable for infants, as they cannot verbally express their pain or point to a photograph to indicate their pain level.
Choice D reason: The FLACC scale, which stands for Face, Legs, Activity, Cry, and Consolability, is an appropriate choice for assessing pain in infants and young children who are non-verbal. It involves observing specific behaviors and assigning a score from 0 to 2 for each category, resulting in a total score between 0 and 10. This observational tool allows healthcare providers to assess pain levels based on the infant's behavior and physiological responses.
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