A nurse is assisting a client with a visual impairment to use the restroom. Which of the following actions will the nurse take to prevent complications?

Increase her voice when speaking to the client

Lower the bed rails before lowering the bed

Use hand gestures to point to where the client will walk

Stand slightly in front and to one side of the client

Answer and Explanation

The Correct Answer is D

Choice A reason: This is incorrect because increasing her voice when speaking to the client may not prevent complications, but rather annoy or offend the client. The nurse should not assume that a client with a visual impairment has a hearing impairment as well unless it is confirmed by assessment or history. The nurse should speak in a normal tone and volume and identify herself by name and role.
Choice B reason: This is incorrect because lowering the bed rails before lowering the bed may increase the risk of complications, such as falls or injuries. The nurse should keep the bed rails up until the client is ready to get out of bed and lower them only when necessary. The nurse should also lock the wheels of the bed and adjust it to a comfortable height for the client.
Choice C reason: This is incorrect because using hand gestures to point to where the client will walk may not prevent complications, but rather confuse or frustrate the client. The nurse should not use visual cues or gestures that are meaningless to a client with a visual impairment. The nurse should use verbal directions and descriptions instead, such as "The restroom is on your left, about 10 steps away."
Choice D reason: This is correct because standing slightly in front and to one side of the client can prevent complications, such as collisions or falls. The nurse should guide the client by offering her arm or shoulder for support and walking slightly ahead of him or her. The nurse should also warn the client about any obstacles or changes in terrain, such as stairs, doors, or rugs.

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Correct Answer is ["E","F"]

Explanation

Choice A Reason: This is incorrect because submerging the client in a cold bath can cause hypothermia, shock, or infection. Cold water can lower the body temperature and blood pressure, which can impair circulation and organ function. Cold water can also introduce bacteria or contaminants into the open wounds. The nurse should use cool water or saline to gently irrigate the burned areas and then cover them with sterile dressings.

Choice B Reason: This is correct because administering oxygen can help the client breathe better and prevent hypoxia. Burns to the face, neck, or chest can cause swelling or damage to the airway, which can impair gas exchange and oxygen delivery. Oxygen can also reduce the risk of carbon monoxide poisoning, which can occur from inhaling smoke or fumes.

Choice C Reason: This is incorrect because restricting fluids can worsen dehydration and shock. Burns can cause significant fluid and electrolyte loss through evaporation and leakage from damaged capillaries. This can lead to hypovolemia, which is low blood volume, and hypotension, which is low blood pressure. The nurse should monitor the client's vital signs, urine output, and weight, and administer intravenous fluids as ordered.

Choice D Reason: This is incorrect because providing a meal high in fiber can cause abdominal discomfort or diarrhea. Burns can cause paralytic ileus, which is a temporary loss of bowel function due to nerve damage or inflammation. This can impair digestion and absorption of food and cause nausea, vomiting, or constipation. The nurse should assess the client's bowel sounds and provide enteral or parenteral nutrition as ordered.

Choice E Reason: This is correct because assessing airway is a priority nursing action for a client with burns. As mentioned above, burns to the face, neck, or chest can compromise the airway and cause respiratory distress or failure. The nurse should assess the client's level of consciousness, breathing rate and pattern, oxygen saturation, and signs of inhalation injury, such as sooty sputum, singed nasal hairs, or hoarseness. The nurse should also be prepared to assist with intubation or tracheostomy if needed.

Choice F Reason: This is correct because applying ice to burned areas can help reduce pain and swelling. Ice can constrict blood vessels and numb nerve endings, which can decrease inflammation and sensation. However, ice should be applied for no more than 15 minutes at a time and wrapped in a cloth or towel to prevent frostbite or tissue damage. Ice should not be applied to large or deep burns.

A. 36 percent B. 54 percent C. 27 percent D. 18 percent E. 9 percent

Correct Answer is A

Explanation

Choice A Reason: This is the correct choice. Using the rule of nines, each arm accounts for 9 percent of TBSA, each leg accounts for 18 percent of TBSA, and front and back are equally divided. Therefore, burns on both sides of both arms and legs equal to (9 + 9) x 2 + (18 + 18) x 2 = 36 percent of TBSA.

Choice B Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 54 percent. To get 54 percent of TBSA, one would have to add burns on both sides of head and neck (9 percent), chest (9 percent), and abdomen (9 percent).

Choice C Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 27 percent. To get 27 percent of TBSA, one would have to subtract burns on both sides of one leg (18 percent).

Choice D Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 18 percent. To get 18 percent of TBSA, one would have to divide burns on both sides of both arms and legs by two.

Choice E Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 9 percent. To get 9 percent of TBSA, one would have to divide burns on both sides of both arms and legs by four.

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A nurse is assisting a client with a visual impairment to use the restroom. Which of the following actions will the nurse take to prevent complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? (Select all that apply.)

Correct Answer is ["E","F"]

Explanation

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

Correct Answer is A

Explanation

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