The nurse is caring for a client with a large abdominal wound. The nurse knows to cleanse the wound from the inner to outer area. What is the rationale for cleaning the wound in this manner?

Prevent introduction of different organisms into the wound

Decrease swelling in wound area from accumulation of organisms

Decrease the pain caused by organisms that may have collected

Render area sterile

Answer and Explanation

The Correct Answer is A

A.   Cleaning the wound from the inner to outer area helps prevent introducing microorganisms from the surrounding skin into the wound, reducing the risk of infection.
B.   While preventing infection may indirectly reduce swelling associated with inflammation, the primary rationale for cleansing the wound in this manner is to minimize the introduction of microorganisms.

C.   Pain reduction is not the primary goal of cleaning the wound from the inner to outer area, although minimizing the risk of infection may help prevent secondary pain caused by infection.
D.   While maintaining a clean environment is essential for wound care, the goal of cleansing the wound in this manner is to reduce the risk of introducing microorganisms, not to achieve sterility.

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Correct Answer is ["A","B","C","D","E"]

Explanation

A. Encouraging the client to cough and deep breathe helps to maintain clear airways and prevent respiratory infections.
B. Turning the client every 2 hours is important for preventing pressure ulcers and maintaining skin integrity.
C. Keeping the skin clean and dry helps to prevent skin breakdown and infections, serving as a barrier against pathogens.
D. Applying lotion to clean skin may keep the skin moisturized hence preventing skin breakdown.

E. Urinary incontinence is associated with skin breakdown hence the development of bedsores. Therefore, assisting the client with voiding is important for maintaining urinary function and skin integrity.

A. supportive interventions as no antibiotic will work with this class of organisms B. an antibiotic to which the organism is sensitive C. wound irrigations with hypotonic solution to wash out the elevated electrolytes D. apply cold to constrict the blood vessels in the wound site

Correct Answer is B

Explanation

A. Staphylococcus aureus is often susceptible to antibiotics, so supportive interventions without antibiotics would not be appropriate.

B. The most appropriate action for treating an infection caused by Staphylococcus aureus would be to administer an antibiotic to which the organism is sensitive.
C. While wound irrigation may be part of the treatment plan for wound infections, using a hypotonic solution to wash out elevated electrolytes is not specifically indicated for Staphylococcus aureus infections.
D. Applying cold to the wound site would not be the primary treatment for a wound infection caused by Staphylococcus aureus. Antibiotic therapy is necessary to address the bacterial infection.

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The nurse is caring for a client with a large abdominal wound. The nurse knows to cleanse the wound from the inner to outer area. What is the rationale for cleaning the wound in this manner?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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