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: Having a bologna sandwich is not a good choice for a client who has hypertension, as bologna is a processed meat that contains high amounts of sodium and saturated fat, which can raise blood pressure and cholesterol levels.
Choice B reason: Seasoning food with vinegar is a good choice for a client who has hypertension, as vinegar is a low-sodium condiment that can add flavor and acidity to food without increasing blood pressure.
Choice C reason: Seasoning food with ketchup is not a good choice for a client who has hypertension, as ketchup is a high-sodium condiment that can increase blood pressure and fluid retention.
Choice D reason: Having canned soup is not a good choice for a client who has hypertension, as canned soup is a high-sodium food that can increase blood pressure and fluid retention. The client should choose low-sodium or homemade soup instead.
Correct Answer is A
Explanation
Choice A reason: Withholding the medication if the systolic blood pressure is less than 90 mm Hg is an appropriate action, as propranolol is a beta-blocker that can lower blood pressure and cause hypotension, which can impair tissue perfusion and cause dizziness, fainting, or shock.
Choice B reason: Requesting a dosage increase if the apical heart rate is less than 60/min is an inappropriate action, as propranolol can slow down the heart rate and cause bradycardia, which can lead to fatigue, weakness, or cardiac arrest. The nurse should monitor the apical pulse before administering propranolol and withhold it if it is less than 60/min.
Choice C reason: Informing the client to expect increased hair growth is an incorrect statement, as propranolol does not cause hypertrichosis or excessive hair growth. However, another beta-blocker, minoxidil, can cause this side effect.
Choice D reason: Administering the medication with an antacid is not an appropriate action, as antacids can interfere with the absorption of propranolol and reduce its effectiveness. The nurse should administer propranolol on an empty stomach or with food that does not contain antacids.
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