The nurse is caring for a client with a large abdominal wound. The nurse knows to cleanse the wound from the inner to outer area. What is the rationale for cleaning the wound in this manner?

Prevent introduction of different organisms into the wound

Decrease swelling in wound area from accumulation of organisms

Decrease the pain caused by organisms that may have collected

Render area sterile

Answer and Explanation

The Correct Answer is A

A.   Cleaning the wound from the inner to outer area helps prevent introducing microorganisms from the surrounding skin into the wound, reducing the risk of infection.
B.   While preventing infection may indirectly reduce swelling associated with inflammation, the primary rationale for cleansing the wound in this manner is to minimize the introduction of microorganisms.

C.   Pain reduction is not the primary goal of cleaning the wound from the inner to outer area, although minimizing the risk of infection may help prevent secondary pain caused by infection.
D.   While maintaining a clean environment is essential for wound care, the goal of cleansing the wound in this manner is to reduce the risk of introducing microorganisms, not to achieve sterility.

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Correct Answer is B

Explanation

A. Allowing the client to ambulate in the hall would not be an appropriate precaution for airborne precautions.

B. This is an appropriate precaution to prevent the nurse from inhaling airborne pathogens.
C. While maintaining distance may help reduce the risk of transmission, wearing appropriate personal protective equipment is essential.
D. Providing a positive air pressure room is not typically a nursing precaution but rather a facility consideration for isolation rooms.

A. Urine characteristics B. Homan's sign C. Lung sounds D. Frequency of diarrhea episodes

Correct Answer is C

Explanation

A. While monitoring urine characteristics is important for overall assessment, it may not be the priority in this situation.
B. Homan's sign is used to assess for deep vein thrombosis and may not be directly related to the client's current symptoms.
C. Elevated temperature after knee replacement surgery could indicate a potential infection, including pneumonia, so assessing lung sounds for signs of infection is a priority.

D. Diarrhea may be indicative of gastrointestinal issues but is less likely to be directly related to the client's current symptoms after knee replacement surgery.

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The nurse is caring for a client with a large abdominal wound. The nurse knows to cleanse the wound from the inner to outer area. What is the rationale for cleaning the wound in this manner?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has been placed on airborne precautions. Which of the following in an appropriate nursing precaution?

Correct Answer is B

Explanation

A client had a right knee replaced 4 days ago. The client returns with an elevated temperature for the past 24 hours. Which assessment would the nurse prioritize?

Correct Answer is C

Explanation

A client is admitted with a severe allergic response to a bee sting. Which lab would the nurse expect to be the most elevated on the white blood count (WBC) differential?

A nurse is concerned about a client's ability to withstand exposure to pathogens. Which blood component should the nurse monitor?

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A nurse is instructing an unlicensed assistive personnel (UAP) on the use of personal protective equipment while caring for clients. Which of the following statements made by the UAP indicates an understanding of standard precaution techniques?

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