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 D
Explanation
Choice A reason: PaO2 85 mmHg is within the normal range of 80 to 100 mmHg and does not indicate any hypoxemia or oxygen deficiency.
Choice B reason: pH 7.47 is within the normal range of 7.35 to 7.45 and does not indicate any acid-base imbalance.
Choice C reason: HCO3 25 mEq/L is within the normal range of 22 to 26 mEq/L and does not indicate any metabolic disturbance.
Choice D reason: PaCO2 55 mmHg is above the normal range of 35 to 45 mmHg and indicates respiratory acidosis, which is a condition where the lungs cannot eliminate enough carbon dioxide and the blood becomes too acidic. This can be caused by pneumonia, which can impair gas exchange and ventilation.
Correct Answer is A
Explanation
Choice A: This is correct because placing electrical cords against the wall can prevent tripping and falling, which can cause injury or dislocation of the hip prosthesis. The nurse should instruct the client to remove any clutter or obstacles from the floor and use assistive devices such as a walker or cane.
Choice B: This is incorrect because placing a throw rug next to the bathtub can increase the risk of slipping and falling, especially when the floor is wet. The nurse should instruct the client to avoid using throw rugs or mats and install grab bars and non-skid mats in the bathroom.
Choice C: This is incorrect because keeping pot handles turned toward the edge of the stove can cause burns or spills, which can also lead to falls or infections. The nurse should instruct the client to turn pot handles inward or use the back burners of the stove.
Choice D: This is incorrect because storing extra blankets in a box on the steps can obstruct the access to the stairs and pose a hazard for falling. The nurse should instruct the client to store extra blankets in a closet or drawer and use handrails when using the stairs.
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