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. The Sims' position is not used for a colposcopy, which is a procedure that examines the cervix with a magnifying device. The client should be placed in the lithotomy position, which involves lying on the back with the legs spread and supported by stirrups.

Choice B: This is incorrect. The nurse should not insert a tampon following the procedure, as this can introduce bacteria and cause infection. The nurse should advise the client to use sanitary pads instead.

Choice C: This is correct. The nurse should instruct the client to avoid sexual intercourse until the cervix is healed, which can take up to a week. Sexual intercourse can cause bleeding, pain, and infection.

Choice D: This is incorrect. The nurse should not reinforce teaching that the procedure involves dilation of the cervix, as this is not true. A colposcopy does not require dilation of the cervix, unlike some other procedures such as endometrial biopsy or hysteroscopy.

A. I can apply lotion between my toes after showering. B. I can wear open-toe shoes. C. I should wear cotton socks. D. I should round the corners of my toenails when trimming them.

Correct Answer is C

Explanation

Choice A: This is incorrect because applying lotion between the toes can create a moist environment that promotes fungal growth and infection. The client should apply lotion to the feet but avoid the areas between the toes.

Choice B: This is incorrect because wearing open-toe shoes can expose the feet to injury and infection. The client should wear well-fitting, closed-toe shoes that protect the feet and prevent pressure ulcers.

Choice C: This is correct because wearing cotton socks can help keep the feet dry and prevent fungal infections. Cotton socks also provide cushioning and reduce friction.

Choice D: This is incorrect because rounding the corners of the toenails can cause ingrown nails, which can lead to infection and ulceration. The client should trim the toenails straight across and file any sharp edges.

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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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