A patient has a nursing diagnosis of infection, related to inadequate primary defenses, as evidenced by surgical incision and intravenous (IV) line access. An appropriate nursing intervention for this patient is to:

Require the use of a facemask by nursing staff when they are providing care.

Maintain "clean" technique in the change of wound dressing and IV site.

Assess and document skin condition around the incision and IV site at each shift.

Limit visitors to immediate family to decrease exposure to infection.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Requiring the use of a facemask by nursing staff is not sufficient alone as a nursing intervention for a surgical incision and IV line access. Comprehensive infection control measures are needed.

Choice B rationale

Maintaining "clean" technique is important, but "sterile" technique would be more appropriate for wound dressing changes and IV site care to prevent infection.

Choice C rationale

Assessing and documenting skin condition around the incision and IV site at each shift is correct because it helps in early identification of signs of infection, ensuring timely intervention.

Choice D rationale

Limiting visitors to immediate family may help reduce infection exposure, but it does not address the primary nursing intervention for monitoring and caring for the surgical incision and IV site.

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Correct Answer is C

Explanation

Choice A rationale

Washing hands after glove removal is not directly related to preventing latex allergy, which is better managed by avoiding latex products and using alternative materials.

Choice B rationale

Washing hands does not enhance the ease of donning a fresh pair of gloves but is critical for removing any contaminants that may have come in contact with the hands during glove removal.

Choice C rationale

The primary reason for washing hands after removing gloves is to avoid the transfer of organisms. Hands can become contaminated during glove removal, and washing them ensures that any potential pathogens are removed.

Choice D rationale

While washing hands can help keep the skin from cracking and drying, this is not the main reason for handwashing after glove removal. The main goal is to maintain proper hygiene and prevent the spread of infection. .

A. Using disposable gloves after hand hygiene when feeding the infant. B. Keeping fingernails short and avoiding wearing rings. C. Washing hands up to the elbows for 2 minutes the first time in the day, and for 1 minute after a diaper change. D. Home care requires less attention to medical asepsis, so hand hygiene is necessary only after toileting or handling soiled diapers.

Correct Answer is B

Explanation

Choice A rationale

While disposable gloves can reduce the transmission of pathogens, they should not replace proper hand hygiene. Gloves should be used when handling bodily fluids or when contact with infectious materials is likely, not necessarily for feeding an infant.

Choice B rationale

Keeping fingernails short and avoiding rings reduces the risk of harboring pathogens under nails and jewelry, which can be difficult to clean properly. This measure helps prevent the transmission of infections.

Choice C rationale

Washing hands up to the elbows is not necessary for routine home care and can cause skin irritation. Hand washing should focus on the hands and wrists, and the duration should be at least 20 seconds.

Choice D rationale

Home care still requires strict attention to medical asepsis, especially when caring for infants. Hand hygiene is necessary not only after toileting or handling soiled diapers but also before and after preparing food, feeding, and other activities.

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A patient has a nursing diagnosis of infection, related to inadequate primary defenses, as evidenced by surgical incision and intravenous (IV) line access. An appropriate nursing intervention for this patient is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse using protective nonsterile gloves in the provision of patient care will wash his or her hands after removal of the gloves in order to:

Correct Answer is C

Explanation

A nurse teaching family members about hand hygiene in the home would emphasize:

Correct Answer is B

Explanation

The nurse is aware that the use of ethylene oxide gas is reserved for the sterilization of:

A patient has been diagnosed with vaginal candidiasis. The nurse recognizes that this condition is usually the result of:

When he is using a needle stick, he should:

A patient has been diagnosed with Creutzfeldt-Jakob disease (mad cow disease). The nurse recognizes this disease is caused by a:

When the nurse performs a procedure using sterile technique in the patient's unit, it means that:

Health personnel should wash their hands with soap and water at the beginning of the shift for:

The nurse explains to the patient who has pneumococcal pneumonia that the lungs serve as the:

A nurse caring for a client who requires isolation has just finished a care procedure. Which of the following pieces of personal protective equipment (PPE) should the nurse remove last?