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. Cottage cheese. B. Orange slices. C. Bran cereal. D. Applesauce.

Correct Answer is D

Explanation

Choice A rationale

Cottage cheese is a dairy product that is high in protein and calcium, but it can be difficult to digest when the gastrointestinal tract is recovering from diarrhea. Its lactose content can worsen diarrhea symptoms, especially in individuals with lactose intolerance. Including low-lactose or lactose-free foods is preferable during this phase of recovery to avoid irritation of the gastrointestinal lining.

Choice B rationale

Orange slices are acidic and contain high levels of vitamin C and citric acid, which can irritate the gastrointestinal mucosa in clients recovering from diarrhea. Additionally, the fructose content can exacerbate diarrhea in some individuals by promoting osmotic effects in the gut. It is important to focus on low-acid, easily digestible foods during recovery.

Choice C rationale

Bran cereal is rich in insoluble fiber, which increases stool bulk and can accelerate intestinal transit time. This property is beneficial for constipation but contraindicated in diarrhea recovery. High-fiber foods can irritate the bowel, hindering mucosal healing and prolonging symptoms, making this a poor dietary choice in this context.

Choice D rationale

Applesauce is low in insoluble fiber and high in soluble fiber, specifically pectin, which has binding properties that help to firm stools. It is gentle on the gastrointestinal tract and promotes healing by forming a protective barrier over the mucosa. The potassium content can also help replenish electrolytes lost during diarrhea, making it a suitable choice for recovery.

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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?