Tube Care / Infection Control Practices / Wound Care

A client has a wound with a moderate amount of drainage and is scheduled for a dressing change. Which dressing, if selected by the student nurse, requires further intervention by the nursing instructor? -Foam -Alginate dressing -Hydrocolloid dressing -Semipermeable transparent film

-Semipermeable transparent film **Semipermeable transparent films are applied to dry wounds. **The client's wound has moderate drainage. Recall that foam, alginate, and hydrocolloid dressings are applied to wounds with moderate to heavy drainage.

The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? -Notify the surgeon. -Clamp the surgical drain. -Change the dressing as prescribed. -Remove and replace the perineal packing.

-Change the dressing as prescribed. **Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore, the nurse needs to change the dressing as prescribed. **A surgical drain would not be clamped because this action will cause the accumulation of drainage within the tissue. The nurse does not need to notify the surgeon at this time because this is expected. Drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse would not remove the perineal packing.

The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is tolerating the procedure if which observation is made? -The skin color becomes cyanotic. -Secretions are becoming bloody. -Coughing occurs with suctioning. -Heart rate decreases from 78 to 54 beats/minute.

-Coughing occurs with suctioning. **Coughing and gagging is common. Coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that the client cannot tolerate the procedure. **The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, and sudden development of bloody secretions. If any of these signs is observed, the nurse immediately stops suctioning and reports the adverse effect to the primary health care provider.

The nurse is caring for a client with a Penrose drain from an abdominal incision. Which is an appropriate nursing intervention for this client? -Ensure that a sterile safety pin is through the drain. -Measure the amount of drainage in a measuring container. -Establish that the drain is at the prescribed amount of suction. -Squeeze the suction device and close the port after emptying the drain.

-Ensure that a sterile safety pin is through the drain. **A Penrose drain is a soft, flat, flexible drain in which 1 end is placed in the wound or incision and the other end is outside the wound. It is an open drainage system that drains onto the skin surface or onto a dressing. It is not sutured in place and thus would have a sterile safety pin (or other device per agency procedure) inserted through it to prevent the drain from going all the way into the wound. **Penrose drain is an open drainage system with no suction and it drains onto the skin or into a dressing, not into a collection container, so the amount of drainage cannot be measured in a measuring container.

Contact precautions are initiated for a client with a nosocomial (health care-associated) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and would obtain which protective items to perform this procedure? -Gloves and gown -Gloves and goggles -Gloves, gown, and shoe protectors -Gloves, gown, goggles, and a mask or face shield

-Gloves, gown, goggles, and a mask or face shield **Splashes of body secretions can occur when providing colostomy care. Goggles and a mask or face shield are worn to protect the face and mucous membranes of the eyes during interventions that may produce splashes of blood, body fluids, secretions, or excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated.

The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse would perform which actions for this procedure? Select all that apply. -Keeping a supply of suction catheters at the bedside -Auscultating breath sounds to determine the need for suctioning -Hyperoxygenating the client before, during, and after suctioning -Intermittently suctioning during insertion of the suction catheter -Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed

-Keeping a supply of suction catheters at the bedside -Auscultating breath sounds to determine the need for suctioning -Hyperoxygenating the client before, during, and after suctioning **Suction equipment needs to be kept at the bedside of an unconscious client, regardless of whether an artificial airway is used. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently, to determine whether suctioning is needed. The client needs to be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. **Intermittent suction would be applied while the catheter is being withdrawn, not while it is being inserted. Suctioning would not be performed for longer than 10 seconds at a time to prevent cerebral hypoxia and a rise in intracranial pressure.

The nurse is assisting a client to collect a midstream urine specimen. How would the nurse implement aseptic technique? -Cleansing the meatus with antiseptic pads using upward strokes -Letting go of the labia once this tissue is cleansed to allow the client to urinate -Making sure that the fingers avoid touching the inside of the collection container -Instructing the client to urinate in the container after the labia have been cleansed

-Making sure that the fingers avoid touching the inside of the collection container **The inside of the container is sterile, and sterility must be maintained. Fingers touching the inside of the container would cause the container to become unsterile. **The meatus would be cleansed from front to back (toward the anus). Upward strokes would bring bacteria from the anal region toward the urinary meatus. The labia would remain open during the procedure. If they are allowed to close, this tissue will have to be cleansed again with the antiseptic pads. The client would void a small amount into the toilet before urinating into the specimen container to allow some of the organisms near the meatus to leave the area.

Two nurses are leaving the room of a client whose care required them to wear a gown, mask, and gloves. Which action by these nurses could lead to the spread of infection? -Taking off the gloves first before removing the gown -Removing the gown without rolling it from inside out -Washing the hands after the entire procedure has been completed -Removing the gloves and then removing the gown using the neck ties

-Removing the gown without rolling it from inside out **The gown must be rolled from inside out to prevent the organisms on the outside of the gown from contaminating other areas. **Gloves are considered the dirtiest piece of equipment and therefore must be removed first. Hands must be washed after removal of the protective garb to remove any unwanted germs still present. Ungloved hands need to be used to remove the gown to prevent contaminating the back of the gown with germs from the gloves.

The nurse is caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse would assess for which characteristic of wound drainage expected in the immediate postoperative period? -Serous -Grossly bloody -Serosanguineous -Serous with sputum

-Serosanguineous **Immediately after radical neck dissection, the client will have a wound drain in the neck attached to portable suction that drains serosanguineous fluid. In the first 24 hours after surgery, the drainage may total 80 to 120 mL. The remaining options are not expected findings.

The nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains which item from the unit supply area for use in applying pressure to the site after removing the IV catheter? -Band-Aid -Alcohol swab -Sterile 2 × 2 gauze -Povidone-iodine swab

-Sterile 2 × 2 gauze **A dry sterile dressing, such as sterile 2 × 2 gauze, is used to apply pressure to the discontinued IV site. This material is absorbent, sterile, and nonirritating. This would be a pressure dressing. **A povidone-iodine swab or alcohol swab would irritate the opened puncture site and would not stop the blood flow. A Band-Aid may be used to cover the site after hemostasis has occurred.

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate? -Continue to suction. -Stop the procedure and reoxygenate the client. -Ensure that the suction is limited to 15 seconds. -Notify the primary health care provider immediately.

-Stop the procedure and reoxygenate the client. **During suctioning, the nurse would monitor the client closely for adverse effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.

The nursing instructor is observing a student nurse donning a pair of sterile gloves and preparing a sterile field. Which observation made by the instructor indicates the need for further teaching? -The student puts on the right glove and then the left glove. -The student dons the sterile gloves without washing the hands. -The student uses the inner wrapper of the gloves as a sterile field. -The student touches a glove on the overbed table, removes both gloves, and dons another sterile pair.

-The student dons the sterile gloves without washing the hands. **Hands must always be washed (even though sterile gloves are used) to keep germs from spreading. **The order of placing gloves on is up to the user, as long as sterile technique is not broken. The inside wrapper provides an excellent area for use because it is sterile. If the gloves touch anything unsterile, they must be considered contaminated, and a new package of gloves must be obtained and used.

The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which dressing would the nurse expect to be prescribed in the treatment of this wound? -Hydrogel dressing -Transparent dressing -Antimicrobial dressing -Calcium alginate dressing

-Transparent dressing **A stage 1 pressure injury is characterized by intact skin with nonblanchable erythema. Dressings used to manage a stage1 pressure injury include transparent dressings, hydrocolloid dressings, or no dressing and leaving the wound open to air. The wound should resolve without epidermal loss over a period of 7 to 14 days.