A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take?

A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds: Capillary refill time is not directly related to the placement of the pulse oximetry probe.
Capillary refill is assessed to evaluate peripheral perfusion.
B. Use an adhesive oximetry probe for a client who has a latex allergy: The type of probe used for pulse oximetry is important, especially for clients with latex allergies. However, the correct action is to use a nonlatex probe or a probe that is compatible with the client's allergy, not necessarily an adhesive probe.
C. Remove polish from the client's fingernail before applying the oximetry probe: Correct. Nail polish can interfere with the accuracy of pulse oximetry readings, as it may affect light transmission through the nail bed. It is essential to remove nail polish or artificial nails before applying the probe.
D. Lubricate the tip of the oximetry probe: Lubricating the tip of the oximetry probe is not necessary for proper use and may interfere with the accuracy of readings.

The correct answer is Choice B.

Choice A rationale: Placing the client in a room with another client who has pharyngitis is not recommended. Pharyngitis can be caused by various different pathogens, not just streptococci. Co-housing clients with different infections can lead to cross-infection, complicating both clients’ conditions. Therefore, this choice is not the best option.

Choice B rationale: Ensuring that the client wears a surgical mask during transportation throughout the facility is the correct choice. Streptococcal infections are spread through respiratory droplets. A surgical mask can help prevent the spread of these droplets, protecting other clients and healthcare workers in the facility. This is a standard precaution in infection control.

Choice C rationale: Limiting the client’s visitors to visitations of 30 minutes is not necessarily beneficial. The duration of the visit does not significantly impact the risk of transmission as much as the precautions taken during the visit, such as hand hygiene and wearing a mask. Therefore, while limiting visitation time might reduce exposure, it is not the most effective measure to prevent the spread of infection.

Choice D rationale: Providing the client a room with negative pressure airflow of six air exchanges per hour is not necessary for a client with a streptococcal infection. Negative pressure rooms are typically used for clients with airborne diseases, such as tuberculosis. A streptococcal infection is spread through droplets, not airborne transmission, so a negative pressure room would not provide any additional benefit.