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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Lowering the mask below the chin for reuse is incorrect because it can cause contamination. Masks should be discarded after each use to prevent the spread of infectious agents.
Choice B rationale
Removing the mask first before other PPE is incorrect because it can lead to self-contamination. The mask should be removed after the gown and gloves, following proper PPE removal protocols.
Choice C rationale
Discarding the mask only if it is wet and otherwise folding and storing it for reuse is incorrect. Masks should not be reused once they have been worn as they may harbor infectious agents.
Choice D rationale
Untying the bottom ties first, then the top, and disposing of the mask without touching it is correct because it prevents contamination of the hands and ensures safe disposal.
Correct Answer is D
Explanation
Choice A rationale
Poor personal hygiene can contribute to infections but is not the primary cause of vaginal candidiasis. This condition is typically caused by an overgrowth of Candida albicans, which is not solely related to hygiene.
Choice B rationale
Unprotected sex is not a common cause of vaginal candidiasis. Candida albicans, the yeast responsible for this condition, is usually present in small amounts in the vagina and becomes problematic when it overgrows, which is not typically related to sexual activity.
Choice C rationale
Using bath oils may alter the vaginal flora but is not a primary cause of vaginal candidiasis. The condition results from an imbalance in the normal vaginal environment, often due to other factors such as antibiotics.
Choice D rationale
Long-term antimicrobial therapy is a common cause of vaginal candidiasis. Antibiotics can disrupt the natural balance of bacteria in the vagina, allowing Candida to overgrow and cause infection.
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