(Select all that apply):. A nurse is providing wound care instructions to a patient who has a contaminated wound. Which actions should the nurse include in the instructions? (Select all that apply)

Choice A rationale:

The nurse should not advise the patient to apply iodine, hydrogen peroxide, or alcohol to the wound. These substances can be irritating to the wound and delay the healing process.

Choice B rationale:

Cleaning and debriding the wound as soon as possible is an essential action to prevent infection and promote healing. Removing debris and foreign material from the wound reduces the risk of contamination and infection.

Choice C rationale:

Using non-sterile instruments for wound care is not appropriate. The nurse should emphasize the importance of using clean and sterile instruments to prevent introducing additional bacteria into the wound.

Choice D rationale:

Administering the Td vaccine (Tetanus and Diphtheria) for prophylaxis is a crucial action to protect the patient from tetanus, especially in contaminated wounds where tetanus spores might be present.

Choice E rationale:

Proper disposal of animal feces is crucial to avoid exposure to tetanus spores. Tetanus spores can be found in soil contaminated with animal feces and can enter the body through open wounds, leading to a serious and potentially fatal infection.

Choice A rationale:

(Incorrect) The herpes zoster vaccine (shingles vaccine) is not administered to patients with chickenpox. The vaccine is recommended for those aged 50 years and older to prevent shingles in individuals who have previously had chickenpox.

Choice B rationale:

(Incorrect) Encouraging contact with immunocompromised individuals is not appropriate when caring for a patient with chickenpox. Immunocompromised individuals are more susceptible to severe complications from the varicella-zoster virus, so close contact should be avoided.

Choice C rationale:

(Correct) Using cool compresses is an essential comfort measure for patients with chickenpox. Cool compresses can help soothe the itching and discomfort caused by the chickenpox rash.

Choice D rationale:

(Incorrect) Providing educational materials only to the patient is not sufficient. It is important for the nurse to educate the patient's family members or caregivers about chickenpox precautions and care to prevent further transmission of the virus.