The mother of a newborn baby is concerned that the baby will develop illnesses from being around people from outside the family. What is the nurse’s best response?

Choice A reason: Putting on nonsterile gloves is the first action that the nurse should take before performing a wound culture. This is to protect the nurse from exposure to blood and body fluids and to prevent crosscontamination. Nonsterile gloves are sufficient for wound care as long as the wound is not sterile or infected.

Choice B reason: Gently removing the soiled dressings is the second action that the nurse should take after putting on nonsterile gloves. This is to expose the wound and prepare it for irrigation and culture. The nurse should discard the soiled dressings in a biohazard bag and observe the wound for any signs of infection, such as redness, swelling, or odor.

Choice C reason: Irrigating the wound is the third action that the nurse should take after removing the soiled dressings. This is to cleanse the wound and remove any debris or bacteria. The nurse should use sterile normal saline or an antiseptic solution as prescribed by the provider and irrigate the wound with a syringe or a spray bottle. The nurse should avoid touching the wound with the irrigation device and collect the runoff in a basin or a towel.

Choice D reason: Labeling the specimen tube is the last action that the nurse should take after irrigating the wound and obtaining the culture. This is to ensure that the specimen is correctly identified and processed by the laboratory. The nurse should label the tube with the client's name, date, time, and site of the wound. The nurse should also document the procedure and the wound assessment in the client's chart.

Choice A reason: Cleansing the skin routinely after soiling occurs is an effective intervention to prevent skin injury. This is because soiling from urine, feces, sweat, or wound drainage can irritate the skin and cause inflammation, infection, or breakdown. The nurse should use a gentle cleanser and warm water and pat the skin dry. The nurse should also avoid using harsh chemicals, alcohol, or perfumes on the skin.

Choice B reason: Applying moisturizer to dry areas of skin is an effective intervention to prevent skin injury. This is because dry skin is more prone to cracking, peeling, or tearing. The nurse should use a hypoallergenic moisturizer and apply it to the skin after cleansing and drying. The nurse should also avoid using products that contain alcohol, fragrances, or dyes on the skin.

Choice C reason: Using a Hoyer lift for all transfers is an effective intervention to prevent skin injury. This is because a Hoyer lift is a mechanical device that helps to lift and move the client safely and comfortably. It reduces the friction and shear on the skin by lifting the client off the bed surface and avoiding any sliding or dragging. It also prevents the nurse from injuring themselves by lifting the client manually.

Choice D reason: Massaging the client’s reddened shoulders and heels is not an effective intervention to prevent skin injury. In fact, this may worsen the skin injury by increasing the pressure and damage to the tissues. The nurse should avoid massaging any areas that are reddened, swollen, or blistered, as these are signs of pressure ulcers. The nurse should instead relieve the pressure by repositioning the client or using pressurerelieving devices, such as pillows, foam pads, or air mattresses.

Choice E reason: Repositioning the client once per shift is not an effective intervention to prevent skin injury. This is because repositioning the client once per shift is not frequent enough to prevent the development of pressure ulcers. Pressure ulcers are caused by prolonged pressure on the skin that reduces the blood flow and oxygen to the tissues. The nurse should reposition the client at least every 2 hours or more often if needed, depending on the client's condition and risk factors.