(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 ["A","B"]
Explanation
Choice A rationale:
(Correct) Excluding infected individuals from school or work until all lesions are crusted over is an important measure in preventing the spread of chickenpox. This helps to reduce the risk of transmission to others.
Choice B rationale:
(Correct) Practicing good hand hygiene is essential to prevent the spread of the varicella-zoster virus, which causes chickenpox and shingles. Regular handwashing helps reduce the likelihood of virus transmission through contact with contaminated surfaces or infected individuals.
Choice C rationale:
(Incorrect) Sharing personal items such as towels with infected individuals can increase the risk of spreading the virus. It is crucial for the nurse to discourage such practices during the community class.
Choice D rationale:
(Incorrect) While reporting cases of chickenpox or shingles to local health authorities is important for surveillance purposes, it is not a preventive measure for individual protection.
Correct Answer is B
Explanation
Choice A rationale:
Stating that "chickenpox is not contagious once the fever is gone" is incorrect information. Chickenpox is still contagious until all the lesions are crusted over.
Choice B rationale:
The statement "You can spread the virus by scratching the lesions" is accurate. Scratching the chickenpox lesions can cause the fluid from the blisters to be released, and this fluid contains the varicella-zoster virus, which can then infect others.
Choice C rationale:
Stating that "chickenpox can only be transmitted through respiratory droplets" is incorrect. While respiratory droplets are a common mode of transmission, direct contact with the fluid from the lesions is also a significant mode of transmission.
Choice D rationale:
Saying that "the virus can survive on surfaces for up to 24 hours" is incorrect. The varicella-zoster virus is relatively fragile and cannot survive for extended periods on surfaces outside the body. It is primarily transmitted through direct contact or respiratory droplets.
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