A nurse is preparing a client for dressing change and hygiene measures.
Which of the following actions should the nurse take to ensure proper infection control?

Remove the dressing and tape while wearing sterile gloves.

Assess the wound structure using sterile gauze.

Dispose of dressings in the designated waste container.

Wash hands thoroughly before touching the sterile field.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Removing the dressing and tape while wearing sterile gloves is not an appropriate action. Sterile gloves are reserved for direct contact with a sterile field or wound. Contaminating sterile gloves during this step defeats their purpose in infection control.

Choice B rationale

Assessing the wound structure using sterile gauze is not a recognized infection control measure. While sterile gauze minimizes the risk of introducing pathogens, its use does not directly ensure overall infection control during dressing changes.

Choice C rationale

Disposing of dressings in the designated waste container is a standard practice for safe disposal. However, it is not sufficient alone to ensure infection control. Proper hand hygiene and aseptic techniques are equally important.

Choice D rationale

Washing hands thoroughly before touching the sterile field eliminates transient microorganisms that could compromise sterility. It is a critical step in maintaining infection control during dressing changes and hygiene measures. .

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Correct Answer is D

Explanation

Choice A rationale

A small amount of dark red wound drainage, such as 20 mL over 4 hours, is a typical postoperative finding in clients following bowel surgery. This observation indicates normal postoperative healing and does not require immediate intervention, making it a lower priority.

Choice B rationale

Pain at the incision site rated as 6 out of 10 is a moderate pain level that is expected in the postoperative period. While managing pain is important, this is not an urgent priority compared to other clinical findings that indicate systemic compromise or potential complications.

Choice C rationale

Dark yellow urine output totaling 60 mL over 4 hours reflects low urine output but does not meet the oliguria threshold of less than 30 mL per hour. This finding may require further assessment but is not immediately critical compared to symptoms of altered consciousness.

Choice D rationale

A client arousing easily but quickly falling back asleep indicates a potential alteration in consciousness, which can result from hypovolemia, hypoxia, or other complications. This finding is a priority for reporting as it may signify deteriorating neurological or hemodynamic status that requires immediate intervention. .

A. Jugular vein distention. B. Pulmonary congestion. C. Urticaria. D. Hypotension.

Correct Answer is C

Explanation

Choice A rationale

Jugular vein distention suggests fluid overload or congestive heart failure due to increased central venous pressure. This finding is unrelated to allergic reactions and does not indicate the need for diphenhydramine, which is an antihistamine used for allergic symptoms. Monitoring fluid balance and addressing the underlying cause of fluid overload are appropriate interventions for such cases.

Choice B rationale

Pulmonary congestion indicates fluid accumulation in the lungs, often due to left-sided heart failure or volume overload. This is not associated with allergic reactions. Diphenhydramine would not be appropriate for managing this finding as it is not effective for conditions requiring diuresis or cardiac support. Pulmonary congestion requires treatment targeting the underlying etiology, such as diuretics or afterload reduction.

Choice C rationale

Urticaria, also known as hives, is a classic symptom of an allergic reaction. It occurs due to histamine release from mast cells and basophils, leading to localized vasodilation and increased vascular permeability. Diphenhydramine is effective in managing urticaria by antagonizing histamine H1 receptors, thereby reducing itching and swelling caused by the allergic reaction.

Choice D rationale

Hypotension during a transfusion can indicate a severe transfusion reaction, such as anaphylaxis or hemolysis. While diphenhydramine might help alleviate mild allergic symptoms, hypotension requires urgent hemodynamic support and further evaluation to determine its cause. Management may include intravenous fluids, vasopressors, and stopping the transfusion.

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A nurse is preparing a client for dressing change and hygiene measures.Which of the following actions should the nurse take to ensure proper infection control?

Nursing Test Bank

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A nurse is preparing a client for dressing change and hygiene measures.
Which of the following actions should the nurse take to ensure proper infection control?