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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Roundworms are common helminth infections but not the most common. They are typically transmitted through contaminated soil and food.
Choice B rationale
Hookworms are another type of helminth infection that can be common but are primarily transmitted through direct contact with contaminated soil.
Choice C rationale
Tapeworms are less common and are usually acquired through the consumption of undercooked meat.
Choice D rationale
Pinworms are the most common helminth infection, especially in children. They are highly contagious and spread through the ingestion of microscopic eggs from contaminated surfaces or fingers.
Correct Answer is D
Explanation
Choice A rationale
Lowering a used mask below the chin to reuse it later is not safe as it can lead to contamination of the mask and facial area, increasing the risk of infection.
Choice B rationale
Removing the mask first before any other personal protective equipment (PPE) can lead to contamination and is not the recommended sequence for doffing PPE.
Choice C rationale
Discarding the mask only if it is wet and storing it for reuse is not safe. Masks should not be reused, as they can harbor infectious agents and increase the risk of contamination.
Choice D rationale
Untying the bottom ties first, then the top, and disposing of the mask without touching it ensures that the person removing the mask avoids contamination. This method adheres to proper doffing procedures and minimizes the risk of infection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.