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What is not an expected assessment finding in a client with inflammation? (Select all that apply.)

Choice A reason: Send the client back to surgery is not the nurse's next action, because it is premature and inappropriate. Sending the client back to surgery requires a medical order and a clear indication of the need for surgical intervention. The nurse cannot make this decision without first assessing the wound and contacting the provider.

Choice B reason: Call the provider immediately is not the nurse's next action, because it is not the most urgent and relevant. Calling the provider immediately is an important action, but it should be done after assessing the wound and gathering the necessary data. The nurse should be able to report the findings of the wound assessment, such as the size, shape, color, amount, and type of drainage, as well as the vital signs, pain level, and mental status of the client.

Choice C reason: Assess the wound for signs of dehiscence is the nurse's next action, because it is the most urgent and relevant. Assessing the wound for signs of dehiscence is a priority action, because it can identify the cause and severity of the problem. Dehiscence is a complication that occurs when the surgical incision splits open or separates, which can cause increased drainage, pain, and infection. Dehiscence can be caused by factors such as infection, poor wound healing, excessive strain, or trauma. Dehiscence can be detected by inspecting the wound for gaps, edges, or protrusions.

Choice D reason: Prepare to culture the wound is not the nurse's next action, because it is not the most urgent and relevant. Preparing to culture the wound is a possible action, but it should be done after assessing the wound and contacting the provider. Culturing the wound is a procedure that involves collecting a sample of the wound drainage and sending it to the laboratory for analysis, which can help identify the type and source of infection. Culturing the wound requires a medical order and a sterile technique.

Choice A reason: Properly disposing of contaminated equipment is an important infectioncontrol measure, but it is not the most effective way to prevent the spread of pathogens during client care. Contaminated equipment, such as gloves, gowns, masks, or needles, should be disposed of in designated containers or bags to prevent exposure or injury to others. However, this measure does not eliminate the risk of transmission of pathogens from the hands of the health care worker to the client or the environment.

Choice B reason: Discarding used syringes into appropriate containers is an important infectioncontrol measure, but it is not the most effective way to prevent the spread of pathogens during client care. Used syringes, especially those that contain blood or body fluids, should be discarded into punctureresistant, leakproof, and labeled containers to prevent needlestick injuries or exposure to others. However, this measure does not eliminate the risk of transmission of pathogens from the hands of the health care worker to the client or the environment.

Choice C reason: Changing soiled linens is an important infectioncontrol measure, but it is not the most effective way to prevent the spread of pathogens during client care. Soiled linens, especially those that contain blood or body fluids, should be changed and handled with gloves and minimal agitation to prevent contamination or aerosolization of pathogens. However, this measure does not eliminate the risk of transmission of pathogens from the hands of the health care worker to the client or the environment.

Choice D reason: Performing hand hygiene is the most effective way to prevent the spread of pathogens during client care, because it reduces the number of microorganisms on the hands of the health care worker, which are the most common source and mode of transmission of infection. Hand hygiene should be performed before and after contact with the client, after contact with potentially infectious materials, after removing gloves, and before and after performing invasive procedures. Hand hygiene can be performed by washing with soap and water or using alcoholbased hand rubs.