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 D

Explanation

Choice A reason: Prone position is not appropriate for a paracentesis, as it can compress the abdominal organs and make it difficult to access the peritoneal cavity.

Choice B reason: Knees elevated position is not appropriate for a paracentesis, as it can increase the intra-abdominal pressure and reduce the amount of fluid that can be drained.

Choice C reason: Lithotomy position is not appropriate for a paracentesis, as it can expose the genital area and increase the risk of infection or injury.

Choice D reason: Leaning forward position is appropriate for a paracentesis, as it can shift the abdominal organs upward and allow more space for the needle insertion and fluid drainage.

A. Sims B. Modified Trendelenburg C. Semi-Fowler's D. Prone

Correct Answer is C

Explanation

Choice A: This is incorrect because Sims position is used for clients who have lower back pain, abdominal surgery, or enemas. It is not appropriate for clients who have a closed head injury.

Choice B: This is incorrect because modified Trendelenburg position is used for clients who have hypovolemic shock or poor venous return. It is not appropriate for clients who have a closed head injury.

Choice C: This is correct because semi-Fowler's position is used for clients who have increased intracranial pressure, respiratory distress, or head trauma. It elevates the head and chest to reduce cerebral edema and facilitate breathing.

Choice D: This is incorrect because prone position is used for clients who have acute respiratory distress syndrome, spinal cord injury, or pressure ulcers. It is not appropriate for clients who have a closed head injury.

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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

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the preparation of a client who is scheduled for a paracentesis. In which of the following positions should the nurse place the client during the procedure?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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