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 C

Explanation

Choice A rationale

Instilling saline into the tubing is not recommended as it increases infection risks and does not clear secretions effectively. It is contraindicated in tracheostomy care and can harm the patient’s respiratory system.

Choice B rationale

Checking the cuff pressure is essential to prevent complications like tracheal injury or air leaks. However, it does not directly alleviate restlessness or crackles in the lungs caused by secretions.

Choice C rationale

Performing suctioning removes secretions from the tracheostomy tube and airways, improving oxygenation and reducing lung crackles. It is the most effective immediate intervention for this scenario.

Choice D rationale

Increasing humidification prevents secretion thickening but does not address accumulated secretions already causing crackles and respiratory distress.

A. Open sore with irregular borders. B. Dry, scaly patches of skin. C. Redness and warmth around the ulcer site. D. Shiny skin with loss of hair growth.

Correct Answer is A

Explanation

Choice A rationale

Venous stasis ulcers typically present as open sores with irregular borders. This is due to chronic venous insufficiency leading to sustained pressure in lower extremities, impairing blood flow and causing tissue breakdown. The irregular shape results from uneven tissue damage.

Choice B rationale

Dry, scaly patches of skin are indicative of other conditions, such as eczema or psoriasis, rather than venous stasis ulcers. These patches are not directly caused by impaired venous circulation or pressure-induced tissue damage.

Choice C rationale

Redness and warmth around the ulcer site can indicate infection, not the primary characteristic of venous stasis ulcers. Stasis ulcers are more commonly associated with chronic wounds and slow healing due to venous congestion.

Choice D rationale

Shiny skin with loss of hair growth is more commonly observed in arterial insufficiency rather than venous stasis ulcers. Arterial insufficiency leads to inadequate oxygen delivery to tissues, causing trophic changes like shiny skin and hair loss.

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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?

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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?

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?