The nurse instructs a client in infection prevention. Which of the following statements, if made by the client, indicates that the teaching was effective?
The organisms on my skin will not infect my leg wound
I should wash my hands before changing my wound dressing
The drainage from my wound can be rinsed down the kitchen sink
The dressings from my wound can be removed without wearing gloves
The Correct Answer is B
Choice A reason: Stating that skin organisms cannot infect a leg wound is incorrect, as skin flora, like Staphylococcus, can contaminate wounds, especially if hygiene is poor. This misunderstanding indicates ineffective teaching, as proper infection prevention emphasizes reducing bacterial transfer to wounds.
Choice B reason: Washing hands before changing a wound dressing is correct, as it removes pathogens, preventing contamination of the sterile field. Hand hygiene disrupts the transmission of bacteria like MRSA, reflecting effective infection prevention teaching and adherence to aseptic technique.
Choice C reason: Rinsing wound drainage down the kitchen sink is incorrect, as it risks environmental contamination with pathogens. Proper disposal involves biohazard protocols to prevent bacterial spread, indicating this statement reflects a misunderstanding of infection control principles.
Choice D reason: Removing wound dressings without gloves is incorrect, as gloves prevent pathogen transmission from contaminated dressings to the caregiver or environment. This statement shows a lack of understanding of standard precautions, indicating ineffective infection prevention teaching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Metabolic acidosis is characterized by a pH below 7.35 due to increased hydrogen ions or decreased bicarbonate. This results from conditions like diarrhea or lactic acid buildup, reducing the blood’s buffering capacity. The kidneys attempt compensation, but low pH is the hallmark, making this the correct choice.
Choice B reason: PaO2 below 70 mm Hg indicates hypoxemia, affecting oxygen levels, not acid-base balance. Metabolic acidosis is driven by bicarbonate loss or acid accumulation, not oxygenation. This parameter is irrelevant to confirming metabolic acidosis, making this choice incorrect.
Choice C reason: PaCO2 above 45 mm Hg suggests respiratory acidosis, not metabolic acidosis, as it indicates CO2 retention. In metabolic acidosis, PaCO2 may decrease due to compensatory hyperventilation to expel CO2, making this choice incorrect for the expected ABG results.
Choice D reason: HCO3 above 26 mEq/L indicates metabolic alkalosis, not acidosis. In metabolic acidosis, HCO3 is typically below 22 mEq/L due to loss (e.g., diarrhea) or acid overload, reducing buffering capacity. This choice is incorrect as it contradicts the condition’s definition.
Correct Answer is B
Explanation
Choice A reason: Continuing suctioning during decreased oxygen saturation and bradycardia worsens hypoxia, as suctioning removes oxygen from the airway. Administering 50% oxygen is insufficient to rapidly correct severe desaturation, making this action inappropriate compared to stopping suctioning and providing 100% oxygen.
Choice B reason: Discontinuing suctioning prevents further oxygen depletion, as suctioning removes air from the airway, exacerbating hypoxia. Administering 100% oxygen rapidly restores oxygen saturation, addressing bradycardia caused by hypoxemia. This aligns with critical care protocols, making it the best action.
Choice C reason: Preparing for resuscitation is premature unless the patient is unresponsive or in cardiac arrest. Decreased oxygen saturation and bradycardia can often be reversed by stopping suctioning and providing oxygen, making this action less immediate than addressing hypoxia directly.
Choice D reason: Continuing suctioning worsens hypoxia, and epinephrine is not indicated for bradycardia caused by suctioning-related hypoxemia. Epinephrine is used in cardiac arrest or allergic reactions, not routine suctioning complications, making this choice incorrect for the scenario.
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