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Exudate: Exudate refers to the fluid, such as pus or serum, that is discharged from a wound.While exudate may be present in infected wounds, it is not a systemic response.

Pain: Pain is a localized response to tissue injury and may be present in infected wounds, but it is not a systemic response.

Hardening of the tissue: Hardening of the tissue, known as induration, may occur in infected wounds due to inflammation but is not a specific systemic response.

Normal white blood cell count: In wound sepsis, the white blood cell count is typically elevated as part of the body's immune response to infection, not normal.

Decreased pain at the wound site: Increased pain at the wound site is more commonly associated with wound infection, not decreased pain.

Redness and swelling: Redness (erythema) and swelling (edema) are local signs of inflammation and can be present in infected wounds, but they are not specific to wound sepsis and may occur in non-infected wounds as well.

Place a surgical mask on the patient: While a surgical mask may provide some level ofprotection, it is not as effective as an N95 mask in filtering out airborne particles, particularly those associated with TB transmission.

Be sure the patient is wearing a protective gown: Protective gowns are typically used toprevent the transmission of infection through contact with body fluids or contaminated surfaces. However, in the case of TB, airborne precautions, including respiratory protection with masks, are more crucial.

Instruct the patient to wear gloves to radiology: Gloves are not necessary for respiratory protection against TB during transportation to radiology.

Skin color changes: While changes in skin color can be indicative of various skin conditions or circulation problems, assessing for signs of infection is more pertinent during dressing changes to prevent and manage complications.

Decreased pain levels: Older adults may have altered pain perception due to age-related changes or comorbidities. However, assessing for signs of infection takes priority during dressing changes to ensure timely intervention if infection is present.

Changes in blood pressure: Changes in blood pressure may be relevant in certain clinical contexts but are not specifically related to performing dressing changes in older clients.

Povidone-iodine: Povidone-iodine is an antiseptic agent used for skin disinfection but is not recommended for routine hand hygiene, especially in cases of Clostridium difficile infection.

Alcohol-based antiseptic: While alcohol-based hand sanitizers are effective for most routine hand hygiene situations, they may not be sufficient for removing spores of Clostridium difficile. Soap and water are preferred for hand hygiene in cases of C. difficile infection.

Chlorhexidine: Chlorhexidine is an antiseptic agent commonly used for skin disinfection, but like alcohol-based hand sanitizers, it may not effectively remove C. difficile spores. Soap and water are preferred.

When the patient will be resting for at least an hour: There is no specific requirement for the patient to rest after applying ointment to an inflamed skin rash.

In the evening before bed: While applying ointment before bed may be convenient for some patients, it may not be the best time for all patients, especially if the rash requires more frequent application.

In the morning before the patient dresses: Applying ointment in the morning may be appropriate, but it depends on the specific needs of the patient and the frequency of application recommended by the healthcare provider.

Treatment is to continue for 7 days: This aspect of the prescription is clear and does not require clarification.

The appearance of the area is to be documented: Documenting the appearance of the area is a standard nursing practice and does not require clarification from the physician.

The procedure is performed with clean technique: The use of clean technique for the procedure is appropriate for the management of a pressure injury and does not require clarification.

Hand hygiene: Hand hygiene is a measure to break the chain of infection by reducing the number of microorganisms on hands. It is not a reservoir of infection.

Wearing personal protective equipment (PPE): PPE is used to protect healthcare workers and patients from exposure to infectious agents. It does not serve as a reservoir for infection.

Proper disposal of sharps: Proper disposal of sharps is important to prevent needlestickinjuries and transmission of bloodborne pathogens but does not represent a reservoir of infection.