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 D

Explanation

A. Droplet precautions are used for diseases transmitted via respiratory droplets, such as influenza or pertussis.
B. Neutropenic precautions are implemented to protect clients with compromised immune systems from exposure to pathogens, typically in the environment.
C. Airborne precautions are used for diseases transmitted via small droplet nuclei that remain suspended in the air, such as tuberculosis or measles.
D. Contact precautions are appropriate for clients infected or colonized with multidrug-resistant organisms like VRE, requiring the use of gloves and gowns when providing care to prevent transmission.

A. urinary tract infection in a client who is sedentary B. vaginal canal infection in a postmenopausal woman C. respiratory infection contracted from a visitor D. wound infection caused by unwashed hands of a caregiver

Correct Answer is D

Explanation

A. A urinary tract infection in a sedentary client does not inherently suggest a hospital-acquired infection.
B. A vaginal canal infection in a postmenopausal woman does not inherently suggest a hospital-acquired infection.
C. A respiratory infection contracted from a visitor does not inherently suggest a hospital-acquired infection.
D. A wound infection caused by unwashed hands of a caregiver suggests a hospital- acquired infection due to the potential for contamination within the healthcare setting.

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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 caring for a client who has a wound infection. Wound cultures identify the infecting organism as vancomycin-resistant enterococci (VRE). Which type of precautions should the health care team initiate?

Correct Answer is D

Explanation

A nurse is assigned to the following four clients with infections. The nurse realizes that which client has acquired a hospital-acquired infection?

Correct Answer is D

Explanation

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