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 B

Explanation

Choice A rationale

Asking the health care provider if they contaminated their glove and the sterile field is not the most effective response. The provider may not be aware of the contamination, and asking this question does not immediately address the contamination issue. Ensuring the sterile field remains uncontaminated is crucial in preventing infections.

Choice B rationale

Pointing out the possible break in surgical asepsis and providing another set of sterile gloves and a fresh sterile field is the best action. This ensures that the sterile environment is maintained, reducing the risk of infection and promoting patient safety.

Choice C rationale

Not saying anything because it is near the end of the procedure is unsafe. Even if the procedure is almost complete, any contamination can increase the risk of infection. It is essential to address the contamination immediately to ensure patient safety.

Choice D rationale

Reporting the health care provider for violating surgical asepsis and endangering the patient is not an immediate solution. While it is important to report such incidents for future prevention, the priority should be to address the contamination promptly to maintain the sterile field and protect the patient.

A. Request a Foley catheter to be inserted. B. Offer a urinal every 2 hours. C. Encourage fluid intake to keep urine dilute. D. Encourage intake of apple juice to keep urine acidic.

Correct Answer is C

Explanation

Choice A rationale

Requesting a Foley catheter for an older adult patient increases the risk of catheter-associated urinary tract infections (CAUTIs). Avoiding unnecessary catheterization is a better approach to prevent infections.

Choice B rationale

Offering a urinal every 2 hours may not significantly reduce the risk of urinary infections. While it encourages regular voiding, it does not address the need to keep urine dilute to prevent infections.

Choice C rationale

Encouraging fluid intake helps keep urine dilute, which reduces the risk of urinary tract infections. Adequate hydration flushes out bacteria and helps maintain a healthy urinary system.

Choice D rationale

While apple juice can help acidify urine, it is not the primary strategy for preventing urinary infections. Maintaining overall hydration with water is more effective in keeping the urine dilute and reducing infection risk.

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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 is helping the health care provider perform a sterile procedure at the bedside. Halfway through the procedure, the nurse believes the health care provider has contaminated the sterile field. The nurse should:

Correct Answer is B

Explanation

To prevent a urinary infection in an older adult patient who is in traction for a broken femur, the nurse would:

Correct Answer is C

Explanation

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?

The nurse explains that medical asepsis differs from surgical asepsis in that medical asepsis:

The nurse uses the Standard Precautions, as outlined by the Centers for Disease Control and Prevention (CDC), when:

When the nurse is using a syringe and needle to give a patient an injection, he or she should:

A patient is sent home with an open wound that is still infected and being treated with wet-to-dry dressing changes four times a day. Before discharge, in order to prevent infecting other family members, the nurse would teach the patient to:

Fecal matter has contaminated the patient's bed sheet. The nurse should:

The nurse instructing a patient in the home use of disinfectant would include the information that the disinfectant can be used to:

The nurse performing a surgical scrub is aware that the average time for the scrub is: