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: This is incorrect because client status unchanged throughout shift is too vague and does not provide specific details about the client's condition and progress. The nurse should document any changes or interventions that occurred during the shift, such as vital signs, pain level, activity, and drainage.
Choice B: This is correct because abdominal wound dry, without redness is a clear and objective description of the client's wound appearance and healing. The nurse should document any signs of infection or complications, such as redness, swelling, warmth, or purulent drainage.
Choice C: This is incorrect because client received an adequate amount of fluid is too general and does not indicate the exact amount and type of fluid that the client received. The nurse should document the intake and output of the client, including any IV fluids, oral fluids, urine, stool, and drainage.
Choice D: This is incorrect because incision healing well is too subjective and does not reflect the actual assessment of the incision site. The nurse should document the size, color, and condition of the incision, as well as any sutures or staples.
Correct Answer is C
Explanation
Choice A reason: Using NSAIDs for pain relief is not a risk factor for osteoporosis. NSAIDs are nonsteroidal anti-inflammatory drugs that are used to treat pain and inflammation. They do not affect bone density or calcium metabolism.
Choice B reason: Age 45 years is not a risk factor for osteoporosis. Osteoporosis is more common in older adults, especially postmenopausal women, but it can affect anyone at any age. The risk of osteoporosis increases with age, but it is not determined by a specific age.
Choice C reason: Smoking cigarettes is a risk factor for osteoporosis. Smoking can reduce bone mass and increase bone loss by interfering with the production and activity of estrogen, which is a hormone that protects bone health. Smoking can also impair blood circulation and oxygen delivery to the bones, which can affect their growth and repair.
Choice D reason: Regular aerobic exercise is not a risk factor for osteoporosis. Aerobic exercise is a type of physical activity that increases the heart rate and improves cardiovascular fitness. Aerobic exercise can also benefit bone health by stimulating bone formation and increasing bone density. Aerobic exercise can also prevent falls and fractures by improving balance and coordination.
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