A nurse is contributing to the plan of care for a client who has developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care?

Discard soiled wound care supplies in a trash receptacle outside the client's room.

Administer antibiotic therapy before culturing the client's wound.

Instruct visitors to perform hand hygiene for 15 seconds after leaving the client's room.

Place the client in a private room with a private bathroom.

Answer and Explanation

The Correct Answer is D

Choice A reason: Discarding soiled wound care supplies in a trash receptacle outside the client's room is not an appropriate action. The nurse should dispose of contaminated materials in a biohazard container inside the client's room to prevent the spread of infection.

Choice B reason: Administering antibiotic therapy before culturing the client's wound is not an appropriate action. The nurse should obtain a wound culture before starting antibiotic therapy to ensure accurate results and avoid altering the microorganisms present in the wound.

Choice C reason: Instructing visitors to perform hand hygiene for 15 seconds after leaving the client's room is not an appropriate action. The nurse should instruct visitors to perform hand hygiene for at least 20 seconds before and after entering the client's room to reduce the risk of transmitting infection.

Choice D reason: Placing the client in a private room with a private bathroom is an appropriate action. The nurse should implement contact precautions for a client who has an infectious wound with foul-smelling drainage to prevent cross-contamination and protect other clients and staff from exposure.

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Correct Answer is C

Explanation

Choice A: This is incorrect. Vegetable shortening is high in saturated fat and trans fat, which can increase the risk of cardiovascular disease by raising the LDL (bad) cholesterol and lowering the HDL (good) cholesterol.

Choice B: This is incorrect. Lard is animal fat that is high in saturated fat and cholesterol, which can also increase the risk of cardiovascular disease by raising the LDL cholesterol and lowering the HDL cholesterol.

Choice C: This is correct. Canola oil is low in saturated fat and high in monounsaturated fat and omega-3 fatty acids, which can lower the risk of cardiovascular disease by lowering the LDL cholesterol and raising the HDL cholesterol.

Choice D: This is incorrect. Butter is dairy fat that is high in saturated fat and cholesterol, which can also increase the risk of cardiovascular disease by raising the LDL cholesterol and lowering the HDL cholesterol

A. I should call the doctor if I feel bloated after the procedure. B. I will need to make arrangements for a ride home. C. I plan to eat a light breakfast the morning of the procedure. D. I can expect to have a sore throat from the breathing tube.

Correct Answer is B

Explanation

Choice A: This is incorrect because feeling bloated after the procedure is not a reason to call the doctor. Feeling bloated after a colonoscopy is normal due to air being introduced into the colon during the procedure. The client can relieve bloating by passing gas or walking.

Choice B: This is correct because making arrangements for a ride home indicates an understanding of the procedure. The client will receive sedation during a colonoscopy, which can impair their judgment and coordination. The client should not drive or operate machinery until fully recovered from sedation.

Choice C: This is incorrect because eating a light breakfast the morning of the procedure indicates a lack of understanding of the procedure. The client should have nothing by mouth after midnight before a colonoscopy, unless instructed otherwise by the provider. The client should follow a clear liquid diet and take bowel preparation agents as prescribed before the procedure.

Choice D: This is incorrect because having a sore throat from the breathing tube indicates a lack of understanding of the procedure. The client will not have a breathing tube during a colonoscopy, as it does not involve intubation or ventilation. The client may have a mouth guard or bite block to protect their teeth and prevent biting on the endoscope.

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A nurse is contributing to the plan of care for a client who has developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

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