A nurse is assisting with the care of a client who has partial-thickness and full-thickness burns to his upper torso and face. Which of the following actions should the nurse take to prevent infection?
Place new linen on the client's bed every other day.
Change gloves between sites when providing wound care to multiple wounds.
Change the dressing on infected wounds first.
Monitor vital signs every 4 hr.
The Correct Answer is B
A. Place new linen on the client's bed every other day: While changing linen regularly is important for maintaining cleanliness and preventing infection, waiting every other day may not be sufficient for a client with burns, especially if there is wound drainage or soiling. Linens should be changed more frequently, ideally daily or as needed, to ensure cleanliness and prevent the spread of infection.
B. Change gloves between sites when providing wound care to multiple wounds: This is a correct action. Changing gloves between sites when providing wound care helps prevent the spread of infection from one wound to another. It reduces the risk of cross-contamination and helps maintain a sterile environment during wound care procedures.
C. Change the dressing on infected wounds first: This is incorrect. Dressings on infected wounds should be changed promptly to prevent the spread of infection. However, changing the dressing on infected wounds first may lead to contamination of other wound sites if proper precautions are not taken. It's important to follow proper infection control procedures, including changing gloves between wound sites and using aseptic technique.
D. Monitor vital signs every 4 hr: Monitoring vital signs is important for assessing the client's overall condition, but it is not directly related to preventing infection. Vital signs may indicate signs of infection, such as fever or increased heart rate, but they do not prevent infection on their own. Other measures, such as wound care and infection control practices, are more directly related to preventing infection in clients with burns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Adhere to strict dietary reduction of oily foods:
Dietary changes, particularly reducing oily and greasy foods, are often recommended as a measure to manage acne. However, the evidence supporting this recommendation is mixed, and strict dietary restrictions may not be necessary for all individuals with acne. Therefore, while the nurse might mention the potential impact of diet on acne, strict dietary reduction of oily foods is not typically the primary focus of acne treatment.
B. Express the larger comedones periodically:
Expressing or squeezing comedones (blackheads or whiteheads) can lead to further inflammation, scarring, and infection. It is not recommended to express comedones at home without proper training and technique. Attempting to express comedones can exacerbate acne and may cause more harm than good.
C. Minimize sun exposure:
Sun exposure can worsen acne and lead to increased inflammation and hyperpigmentation. Therefore, it is important for individuals with acne to minimize sun exposure and use sunscreen with a broad-spectrum SPF of 30 or higher.
D. Use friction when washing the face:
Excessive friction or aggressive scrubbing when washing the face can irritate the skin and worsen acne. Instead, the nurse should advise gentle cleansing of the face using a mild, non-comedogenic cleanser and lukewarm water. Harsh scrubbing or using abrasive cleansers can disrupt the skin barrier and exacerbate acne symptoms.
Correct Answer is D
Explanation
A. Baseball games: Participating in baseball games may involve running, jumping, and sudden movements that could potentially strain the surgical area or cause discomfort. It's best to avoid strenuous physical activities like baseball until the child has fully recovered from orchiopexy.
B. Running around the playground: Running around the playground may also involve vigorous physical activity that could potentially affect the surgical site. It's advisable to limit activities that involve running or jumping until the child's healthcare provider gives clearance.
C. Horseback riding: Horseback riding involves sitting on a horse and may put pressure on the groin area, where the surgical site is located. It's generally recommended to avoid activities like horseback riding until the child has fully healed from orchiopexy.
D. Puzzle games: Puzzle games are typically low-impact activities that do not involve physical exertion or strain on the surgical area. Engaging in quiet, seated activities like puzzle games can be suitable for a child who is recovering from orchiopexy and may help keep them entertained during the recovery period.
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