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 A

Explanation

Choice A reason: Difficulty swallowing is a sign of anaphylaxis, which is a severe allergic reaction that can cause swelling of the throat and tongue, leading to airway obstruction and respiratory distress.

Choice B reason: Petechial rash on the abdomen is not a sign of anaphylaxis, but rather a sign of thrombocytopenia, which is a low platelet count that can cause bleeding under the skin.

Choice C reason: Hypertension is not a sign of anaphylaxis, but rather a sign of high blood pressure, which can be caused by various factors such as stress, pain, or kidney disease.

Choice D reason: Bilateral tinnitus is not a sign of anaphylaxis, but rather a sign of hearing loss or damage, which can be caused by exposure to loud noise, ear infection, or medication side effects.

A. Provide the client with small-handled adaptive utensils. B. Describe the food placement as though the plate were a clock. C. Discourage conversations during the client's mealtime. D. Arrange for an assistive personnel to feed the client.

Correct Answer is B

Explanation

Choice A reason: Providing the client with small-handled adaptive utensils is not necessary for a visually impaired client. The client may prefer to use their own utensils or regular ones that they are familiar with.

Choice B reason: Describing the food placement as though the plate were a clock is a helpful technique to orient the client to their meal and avoid spills or accidents. The nurse should also ask the client about their preferences and needs before serving the food.

Choice C reason: Discouraging conversations during the client's mealtime is not appropriate for a visually impaired client. The nurse should encourage social interactions and respect the client's dignity and autonomy.

Choice D reason: Arranging for an assistive personnel to feed the client is not indicated for a visually impaired client. The nurse should promote the client's independence and self-care abilities as much as possible.

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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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