When assessing a client with a new contaminated wound, which is the most important factor for the nurse to assess?
1. The cleanliness of the object that caused the wound
2. The presence of any rust on the object that caused the wound
3. When the client last had a tetanus toxoid
4. Where the client was when the wound occurred
Correct Answer: 3
When caring for a client with a contaminated wound, it is important to determine when the last tetanus shot was administered, and to provide a booster, if indicated. The cleanliness of the object is less important information, and even if the client were to report cutting with a "clean" knife, the likelihood of pathogens on the knife is high if it wasn't sterilized. The absence of visible rust on the object would not make the cut any less contaminated, so this is not valuable information. In most instances, the location of the occurrence of the wound would not be valuable information.
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