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 D
Explanation
Choice A reason: Metabolic alkalosis and warm extremities are not typical of postoperative shock. Shock, often hypovolemic or septic post-surgery, causes hypotension and poor perfusion, leading to cool extremities and acidosis from tissue hypoxia. Alkalosis and warm extremities suggest other metabolic or circulatory conditions, not shock.
Choice B reason: Bradycardia and bradypnea are not primary features of postoperative shock. Hypovolemic or septic shock typically causes tachycardia and tachypnea as compensatory responses to reduced perfusion and oxygen delivery. These slowed vital signs suggest other conditions, like neurological issues, not shock.
Choice C reason: Hypertension and anuria are not characteristic of postoperative shock. Shock typically presents with hypotension due to reduced blood volume or vasodilation, and anuria may occur later but is not primary. Hypertension suggests other causes, like pain or fluid overload, not shock.
Choice D reason: Hypotension and confusion are hallmark signs of postoperative shock, often hypovolemic or septic. Hypotension results from reduced blood volume or vasodilation, impairing tissue perfusion, while confusion reflects cerebral hypoxia. These symptoms align with shock’s systemic impact on circulation and organ function.
Correct Answer is C
Explanation
Choice A reason: Decreased renal blood flow and urine concentration in older adults can lead to reduced kidney efficiency, affecting fluid balance. However, these changes primarily cause issues like nocturia or polyuria, not directly incontinence. Incontinence in this context is more related to physical limitations than renal function, making this explanation less relevant.
Choice B reason: The statement about kidneys reaching maximum size at ages 35 to 40 is factually inaccurate and irrelevant to incontinence. Kidney size does not directly correlate with urinary control. Incontinence in older adults, especially those wheelchair-bound, is more likely due to mobility or neurological issues, not kidney size.
Choice C reason: Mobility issues, such as being wheelchair-bound, can cause urinary incontinence by limiting timely access to toileting facilities. This leads to functional incontinence, where physical limitations prevent reaching the bathroom. In older adults, reduced mobility exacerbates bladder control issues, making this the most accurate explanation for the daughter.
Choice D reason: Variations in voiding frequency may occur in older adults due to bladder changes or medications, but this does not directly cause incontinence. Frequency may contribute to urgency, but the primary issue in a wheelchair-bound client is likely mobility-related, making this explanation less precise than mobility issues.
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