A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take to help prevent an incisional infection?
Clean the incision with soap and water.
Perform hand hygiene prior to dressing changes.
Initiate protective isolation.
Allow the wound to air periodically.
The Correct Answer is B
Choice A reason: Cleaning the incision with soap and water is not typically recommended as it can disrupt the healing process and may lead to irritation or infection. The incision should be kept clean and dry, and any cleaning should be done according to the surgeon's instructions.
Choice B reason: Performing hand hygiene before dressing changes is essential in preventing incisional infections. Hand hygiene is one of the most effective ways to prevent the spread of infections, including those at surgical sites.
Choice C reason: Protective isolation is used for immunocompromised patients to protect them from infections, not typically for postoperative patients unless they are at high risk for infection due to other conditions.
Choice D reason: Allowing the wound to air can be part of the healing process, but it must be done carefully and under the guidance of healthcare professionals to ensure that the wound is protected from contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Not wearing artificial nails during client care is a recommended practice to prevent the spread of infection, as artificial nails can harbor bacteria.
Choice B reason: Washing hands when they are visibly dirty is correct, but hand hygiene should also be performed at other times, such as before and after patient contact, regardless of the appearance of cleanliness.
Choice C reason: Changing gloves is not a substitute for hand washing. Hand hygiene is necessary before donning gloves and after removing them to prevent the transmission of pathogens.
Choice D reason: Using alcohol-based hand products is a standard practice in healthcare settings and is effective in killing most bacteria and viruses when the hands are not visibly soiled.
Correct Answer is C
Explanation
The correct answer is c. Asking the client to rate the pain. This is the most direct and reliable method to determine the effectiveness of a cold compress for pain relief.
Choice A Reason:
Having the client perform range-of-motion exercises of the arm: This statement is incorrect because it assesses mobility rather than pain or swelling. Range-of-motion exercises are typically used to evaluate joint flexibility and muscle strength, not the effectiveness of pain relief measures.
Choice B Reason:
Inspecting the site for reduced swelling: This statement is incorrect because, while it checks for swelling, it does not directly measure pain relief. Swelling reduction can be an indicator of decreased inflammation, but it does not provide a direct assessment of the client's pain levels.
Choice C Reason:
Asking the client to rate the pain: This is the correct choice because it directly measures the client's perception of pain. Pain is a subjective experience, and the most accurate way to assess it is by asking the client to describe or rate their pain. This method allows the nurse to gauge the effectiveness of the cold compress in providing pain relief.
Choice D Reason:
Monitoring the client's pulse rate: This statement is incorrect because pulse rate is not a direct indicator of pain or swelling reduction. While pain can sometimes cause an increase in pulse rate, it is not a reliable or specific measure of pain relief. Pulse rate can be influenced by various factors, including stress, anxiety, and physical activity.
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