The nurse is caring for a client with a surgical incision. Which action should the nurse take to reduce the client's risk of infection?

Monitor the wound for any redness or purulent drainage.

Assess body temperature at regularly scheduled intervals.

Apply heat to the surgical site to increase blood flow.

Utilize strict aseptic technique during dressing changes.

Answer and Explanation

The Correct Answer is D

A. Monitor the wound for any redness or purulent drainage: Regular assessment helps identify early signs of infection, but it does not actively prevent infection. Monitoring is important for detection, not risk reduction.

B. Assess body temperature at regularly scheduled intervals: Measuring temperature can help detect systemic infection, yet it does not prevent the development of a wound infection. It is a monitoring intervention rather than a preventive action.

C. Apply heat to the surgical site to increase blood flow: Applying heat may promote circulation, but excessive or inappropriate heat can increase inflammation or tissue damage. Heat is not a standard preventive measure for surgical site infections.

D. Utilize strict aseptic technique during dressing changes: Aseptic technique minimizes the introduction of pathogens into the wound during dressing changes. Proper hand hygiene, sterile supplies, and careful handling directly reduce the risk of infection and are considered a primary preventive measure in postoperative care.

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Correct Answer is B

Explanation

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. Implement a fluid restriction. B. Provide a high-protein diet. C. Encourage high caffeine beverages. D. Limit the intake of citrus fruits.

Correct Answer is B

Explanation

A. Implement a fluid restriction: Fluid restriction is indicated only in specific conditions such as heart failure or renal failure. Routine postoperative clients typically require adequate hydration to support healing, so restricting fluids is not appropriate.

B. Provide a high-protein diet: Protein is essential for wound healing, tissue repair, and maintaining immune function after surgery. A high-protein diet supports collagen formation, prevents muscle loss, and enhances recovery. This intervention is a standard component of postoperative nutrition care.

C. Encourage high caffeine beverages: Caffeine can lead to dehydration and increased heart rate, which may complicate recovery. High caffeine intake does not support healing and is not recommended as a postoperative nutrition intervention.

D. Limit the intake of citrus fruits: Citrus fruits provide vitamin C, which supports collagen synthesis and immune function. Limiting them is unnecessary unless there is a specific allergy or gastrointestinal intolerance. Their inclusion is generally beneficial for surgical recovery.

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