(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:
Complete Blood Count (CBC) is not useful in confirming the diagnosis of chickenpox. CBC provides information about the number and types of blood cells but is not specific to chickenpox diagnosis.
Choice B rationale:
Stool culture is not relevant in confirming the diagnosis of chickenpox. Stool culture is used to identify gastrointestinal infections, and it is not associated with chickenpox.
Choice C rationale:
Tzanck smear and viral culture from vesicle fluid are useful in confirming the diagnosis of chickenpox. Tzanck smear involves taking a sample from the vesicle and staining it to identify multinucleated giant cells, which are characteristic of varicella-zoster virus (VZV) infection. Viral culture involves growing the VZV in a lab to confirm the presence of the virus.
Choice D rationale:
Urinalysis is not relevant in confirming the diagnosis of chickenpox. Urinalysis is used to assess kidney function and detect urinary tract infections, but it does not help in diagnosing chickenpox.
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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