The nurse is caring for a client after surgery. Which finding should the nurse prioritize to identify a surgical site infection (SSI)?

A. The student nurse performs hand hygiene before opening the sterile kit: Performing hand hygiene is a standard infection prevention measure and is appropriate before handling sterile equipment. It maintains asepsis and does not compromise the sterile field.

B. The student nurse uses their sterile hand to reposition the client's leg: Touching the client with a sterile hand contaminates it and breaches the sterile field. Any contact with nonsterile surfaces requires the sterile hand to be re-gloved and sterile equipment to be replaced to maintain asepsis.

C. The student nurse assesses the client for a latex allergy before beginning the procedure: Screening for latex allergy is appropriate and prevents allergic reactions. This step does not compromise sterility and is a proper safety measure.

D. The student nurse instructs the client not to touch the sterile field during the procedure: Educating the client to avoid the sterile field helps maintain asepsis and is a correct infection control practice. It does not necessitate halting the procedure.

A. Plan: The plan section of a SOAP note outlines the interventions, treatments, and actions that the healthcare team will implement to address the client’s identified problems. It includes nursing interventions, medications, diagnostic tests, and follow-up measures to support the client’s health.

B. Objective: The objective section records measurable, observable data such as vital signs, lab results, and physical assessment findings. It does not specify intended actions or interventions.

C. Subjective: The subjective section documents the client’s personal experiences, feelings, and reports, such as pain or fatigue. It informs care but does not include planned interventions.

D. Assessment: The assessment section provides the clinician’s interpretation of the client’s condition based on subjective and objective data. It identifies problems and potential diagnoses but does not detail planned actions.