A client who has had abdominal surgery develops an infection in the wound while still hospitalized. Which of the following agents is most likely the cause of the infection?

Correct Answer: B

Rationale: The correct answer is B: Bacteria. Bacteria are the most common cause of wound infections, especially in surgical wounds. They can easily enter the body during surgery and cause infections. Viruses typically do not cause wound infections, as they require living cells to replicate. Fungi are less common in wound infections and are usually associated with specific risk factors. Spores are not a common cause of wound infections, as they are usually dormant and require specific conditions to germinate. In summary, bacteria are the most likely cause of the infection in the client's wound due to their ability to easily enter the body during surgery and cause infections.

Correct Answer: C

Rationale: The correct answer is C: Immune response. The immune system is the body's defense mechanism against infections. It recognizes and fights off pathogens like bacteria, viruses, and other harmful substances. The immune response involves various cells and proteins working together to neutralize and eliminate the invading pathogens. Racial characteristics (A) and body shape and size (B) are not directly related to the body's defense against infections. Level of susceptibility (D) may influence an individual's likelihood of getting infected but does not represent an active defense mechanism like the immune response does.

Correct Answer: D

Rationale: The correct answer is D: Urinary catheterization. This procedure carries the greatest risk for a nosocomial infection due to the direct introduction of pathogens into the urinary tract. Steps in catheterization involve breaching the body's natural defense barriers, increasing susceptibility to infections. The other choices (A: Enema, B: Intramuscular injections, C: Heat lamp) do not involve invasive procedures like catheterization, which significantly elevate the risk of nosocomial infections. Enemas and intramuscular injections are typically sterile procedures, while the heat lamp does not involve direct entry into the body, thus posing a lower risk of infection compared to urinary catheterization.

Correct Answer: C

Rationale: The correct answer is C: Risk for Imbalanced Body Temperature. When a client has a serious bacterial infection, the body's response includes fever, which can lead to an imbalance in body temperature regulation. Dehydration can exacerbate this issue. Nursing diagnosis C is the most appropriate as it directly relates to the physical effects of the infection, helping the nurse anticipate and address potential complications. Choice A, High Risk for Infection, is not the best choice as the client already has a bacterial infection, so the risk is not high but rather already present. Choice B, Excess Fluid Volume, is unlikely in a dehydrated client. Choice D, Risk for Latex Allergy Response, is not related to the physical effects of the bacterial infection and dehydration.

Correct Answer: A

Rationale: The correct answer is A because using sterile gloves to handle the entire drape surface ensures the sterility of the working area during the urinary catheterization procedure. By using sterile gloves, the nurse maintains aseptic technique and prevents contamination of the sterile field. Choice B is incorrect because folding the lower edges of the drape over the sterile-gloved hands may lead to contamination of the sterile field as the gloves are not in direct contact with the drape surface. Choice C is incorrect because touching only the outer two inches of the drape when not wearing sterile gloves does not ensure complete sterility and may still lead to contamination of the working area. Choice D is incorrect because allowing clothing to touch the drape can introduce contaminants to the sterile field, compromising the aseptic technique required for the procedure.