(Select all that apply):. A nurse is providing wound care instructions to a patient who has a contaminated wound. Which actions should the nurse include in the instructions? (Select all that apply)
Apply iodine, hydrogen peroxide, or alcohol to the wound.
Clean and debride the wound as soon as possible.
Use non-sterile instruments for wound care.
Administer Td vaccine for prophylaxis.
Dispose of animal feces properly to avoid tetanus spores.
Correct Answer : B,D,E
Choice A rationale:
The nurse should not advise the patient to apply iodine, hydrogen peroxide, or alcohol to the wound. These substances can be irritating to the wound and delay the healing process.
Choice B rationale:
Cleaning and debriding the wound as soon as possible is an essential action to prevent infection and promote healing. Removing debris and foreign material from the wound reduces the risk of contamination and infection.
Choice C rationale:
Using non-sterile instruments for wound care is not appropriate. The nurse should emphasize the importance of using clean and sterile instruments to prevent introducing additional bacteria into the wound.
Choice D rationale:
Administering the Td vaccine (Tetanus and Diphtheria) for prophylaxis is a crucial action to protect the patient from tetanus, especially in contaminated wounds where tetanus spores might be present.
Choice E rationale:
Proper disposal of animal feces is crucial to avoid exposure to tetanus spores. Tetanus spores can be found in soil contaminated with animal feces and can enter the body through open wounds, leading to a serious and potentially fatal infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Monitoring vital signs, fluid intake, and output is important for assessing the client's overall health and hydration status, but it does not specifically address preventing the transmission of the virus.
Choice B rationale:
Providing comfort measures like cool compresses and loose clothing can help alleviate symptoms and discomfort, but it does not directly address preventing the transmission of the virus.
Choice C rationale:
Encouraging oral hygiene and a soft diet is essential for managing the client's symptoms and promoting healing, but it does not focus on preventing the spread of the virus to others.
Choice D rationale:
Isolating the patient until all lesions are crusted over is a crucial nursing intervention to prevent transmission of the chickenpox virus. Chickenpox is highly contagious, primarily spread through respiratory droplets and contact with the fluid from the skin lesions. By isolating the patient until all lesions have crusted over, the risk of spreading the virus to others is significantly reduced.
Correct Answer is C
Explanation
Choice A rationale:
Airborne precautions are used for infectious agents that spread through small respiratory droplets and remain suspended in the air for long periods. Shingles is not transmitted through the airborne route.
Choice B rationale:
Droplet precautions are used for infectious agents that spread through large respiratory droplets and have a limited range. Shingles is not transmitted through large respiratory droplets.
Choice C rationale:
This is the correct response. Contact precautions are implemented for patients with shingles (herpes zoster) because the virus spreads through direct contact with the rash or lesions.
Choice D rationale:
Standard precautions are used for all patients to prevent the transmission of infections from both recognized and unrecognized sources. However, for specific diseases like shingles, additional precautions like contact precautions are also required.
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.