(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 C
Explanation
Choice A rationale:
The varicella vaccine is not effective in preventing chickenpox. This statement is incorrect. The varicella vaccine is actually highly effective in preventing chickenpox. It contains a weakened form of the varicella-zoster virus, which stimulates the body's immune system to develop protection against the virus, reducing the risk of getting chickenpox.
Choice B rationale:
Serious adverse events from the vaccine are common. This statement is incorrect. Serious adverse events from the varicella vaccine are rare. Like all vaccines, there may be some mild side effects such as soreness at the injection site, fever, or a mild rash, but severe reactions are extremely uncommon.
Choice C rationale:
The vaccine has a high efficacy rate in preventing shingles. This statement is correct. The varicella vaccine not only helps prevent chickenpox but also reduces the risk of developing shingles later in life. Shingles is caused by the reactivation of the varicella-zoster virus, and the vaccine helps boost immunity to the virus, leading to a decreased likelihood of shingles.
Choice D rationale:
The vaccine is not recommended for pregnant women. This statement is generally correct. Pregnant women should avoid receiving the varicella vaccine because it is a live attenuated vaccine, and there is a theoretical risk of transmission to the fetus. If a woman is not immune to varicella and is planning to become pregnant, it's best to receive the vaccine before pregnancy.
Correct Answer is C
Explanation
Choice A rationale:
Taking aspirin is not recommended for individuals with chickenpox, especially children, as it has been associated with an increased risk of Reye syndrome, a severe and potentially fatal condition affecting the brain and liver.
Choice B rationale:
Applying topical antibiotics is not a suitable recommendation for relieving pruritus (itching) associated with chickenpox. Topical antibiotics are used to treat bacterial skin infections, not pruritus.
Choice C rationale:
Using antihistamines is the most appropriate recommendation for relieving pruritus in chickenpox. Antihistamines block the effects of histamine, a chemical released during an allergic reaction or infection, and can help reduce itching.
Choice D rationale:
Increasing physical activity is not advised for a client with chickenpox, as this could lead to the spread of the virus to others and may worsen the symptoms and pruritus.
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