what is a key nursing action for a client with a wound infection
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2020

1. What is a key nursing action for a client with a wound infection?

Correct answer: B

Rationale: Performing a wound culture before applying antibiotics is crucial for determining the specific type of infection present and selecting the most effective antibiotic treatment. Changing the dressing daily (Choice A) is a routine wound care practice but may not address the root cause of the infection. Cleansing the wound with alcohol-based solutions (Choice C) can be too harsh and delay wound healing. Applying a wet-to-dry dressing (Choice D) is an outdated practice that can cause trauma to the wound bed and hinder the healing process.

2. A healthcare professional is preparing to administer a blood transfusion. What is the healthcare professional's first action?

Correct answer: B

Rationale: The healthcare professional's first action before administering a blood transfusion should be to verify that the client's blood type matches the blood product. This step is crucial to ensure compatibility and prevent potentially severe transfusion reactions. Checking the client's temperature (Choice A) is important but not the first action in this scenario. Administering the blood through an IV push (Choice C) is incorrect as blood transfusions are typically administered as a slow infusion. Ensuring the blood is warmed before administration (Choice D) is not the first action and is not a standard practice in blood transfusions.

3. A nurse is reviewing the plan of care for a client who is receiving chemotherapy for cancer. Which of the following interventions should the nurse include to prevent infection?

Correct answer: C

Rationale: The correct answer is to instruct the client to use a soft toothbrush. Using a soft toothbrush helps prevent bleeding in clients receiving chemotherapy, who are at risk for mucositis. Encouraging the client to eat high-protein foods (Choice A) is important for overall health but not directly related to preventing infection. Encouraging the client to drink 2 liters of fluid daily (Choice B) is essential for hydration but does not specifically prevent infection. Instructing the client to use a mouthwash containing alcohol (Choice D) is contraindicated as alcohol-containing mouthwashes can cause irritation and dryness in the oral mucosa, increasing the risk of infection.

4. During the admission of a client with a latex allergy, which of the following supplies has the potential to contain latex?

Correct answer: A

Rationale: The correct answer is A: Urinary catheters. Urinary catheters often contain latex, which can trigger an allergic reaction in clients with latex allergy. Indwelling catheters (choice B), sterile gloves (choice C), and sterile gowns (choice D) can be latex-free alternatives. However, urinary catheters are more commonly made with latex, making them a higher risk for clients with latex allergies.

5. How should a healthcare professional manage a patient with an indwelling urinary catheter?

Correct answer: A

Rationale: Monitoring urine output and ensuring proper catheter drainage are crucial aspects of managing a patient with an indwelling urinary catheter. This helps in assessing the patient's renal function, fluid balance, and the patency of the catheter. Administering antibiotics and changing the catheter regularly (Choice B) may not be necessary unless there is an infection present. While monitoring for signs of infection and providing catheter care (Choice C) are important, the primary focus should be on urine output and drainage. Providing a high-sodium diet and monitoring hydration (Choice D) are not directly related to managing an indwelling urinary catheter.

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