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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Blurred vision is not an expected side effect of digoxin, but a sign of digoxin toxicity, which requires immediate medical attention.
Choice B reason: This is the correct answer because digoxin can cause hypokalemia (low potassium levels), which increases the risk of digoxin toxicity. Therefore, clients taking digoxin need to have their potassium levels monitored regularly and consume foods rich in potassium.
Choice C reason: Antacids can interfere with the absorption of digoxin and reduce its effectiveness. Clients taking digoxin should avoid taking antacids within two hours of taking the medication.
Choice D reason: Weighing oneself every other day is not related to digoxin therapy, but to fluid balance. Clients with heart failure, who are often prescribed digoxin, need to monitor their weight daily and report any significant changes to their health care provider.
Correct Answer is C
Explanation
Choice A reason: Doing testicular self-exam every 6 months without fail is not an adequate frequency, as it can delay the detection of any changes or abnormalities in the testes that may indicate cancer or other conditions. Men should perform testicular self-exam monthly, preferably after a warm bath or shower.
Choice B reason: The flu shot received last year will not last for 2 years, as it only provides protection against specific strains of influenza virus that may change from year to year. People should get a flu shot annually, preferably before the flu season starts.
Choice C reason: Examining breasts a week after each menstrual period is an optimal time, as breasts are less likely to be swollen, tender, or lumpy due to hormonal fluctuations. Women should perform breast self-exam monthly, preferably at the same time each month.
Choice D reason: Getting a hepatitis B vaccine on a yearly basis is not necessary, as it only requires three doses at 0, 1, and 6 months to provide lifelong immunity against hepatitis B virus infection. People who are at high risk of exposure to hepatitis B virus should get tested for antibodies before receiving the vaccine series.
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