A patient has a nursing diagnosis of infection, related to inadequate primary defenses, as evidenced by surgical incision and intravenous (IV) line access. An appropriate nursing intervention for this patient is to:
Require the use of a facemask by nursing staff when they are providing care.
Maintain "clean" technique in the change of wound dressing and IV site.
Assess and document skin condition around the incision and IV site at each shift.
Limit visitors to immediate family to decrease exposure to infection.
The Correct Answer is C
Choice A rationale
Requiring the use of a facemask by nursing staff is not sufficient alone as a nursing intervention for a surgical incision and IV line access. Comprehensive infection control measures are needed.
Choice B rationale
Maintaining "clean" technique is important, but "sterile" technique would be more appropriate for wound dressing changes and IV site care to prevent infection.
Choice C rationale
Assessing and documenting skin condition around the incision and IV site at each shift is correct because it helps in early identification of signs of infection, ensuring timely intervention.
Choice D rationale
Limiting visitors to immediate family may help reduce infection exposure, but it does not address the primary nursing intervention for monitoring and caring for the surgical incision and IV site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
No explanation
Correct Answer is C
Explanation
Choice A rationale
Gown, gloves, and a mask are important, but goggles or glasses provide additional protection against splashes, which are common in patients with diarrhea and vomiting.
Choice B rationale
Reusable gowns are generally not recommended in situations where contamination is likely, as they can harbor pathogens even after laundering. Disposable PPE is preferable.
Choice C rationale
Gown, gloves, and goggles (or glasses) offer comprehensive protection. Goggles or glasses shield the eyes from potential splashes, reducing the risk of transmission of infectious agents.
Choice D rationale
Shoe covers are not typically necessary unless there is a risk of floor contamination. The primary focus should be on protecting the areas most likely to be exposed to body fluids, such as the hands, body, and face.
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