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 B
Explanation
Correct answer is B
B. Use a moisturizer to wipe urine from the skin.Using a gentle moisturizer to clean the skin can help protect the infant's skin and maintain its barrier function, especially in cases of diaper dermatitis. Moisturizers help soothe and heal the affected area by providing hydration and protection.
Incorrect options:
A. "Change to cloth diapers until the skin is healed.": While some parents may prefer cloth diapers, they can retain moisture and irritants. Disposable diapers with good absorbency are often preferred in managing diaper dermatitis.
C. "Apply a light layer of talcum powder with each diaper change.": Talcum powder is not recommended due to the risk of inhalation, which can cause respiratory issues. Additionally, powders can clump and worsen skin irritation.
D. "Expose the excoriated area to hot air frequently.": Exposing the skin to hot air can dry out the skin and worsen irritation. It’s better to allow the area to air-dry naturally or use a cool blow dryer on a low setting.
Correct Answer is C
Explanation
A. Orange-tinged urine
- This manifestation is not typically associated with nephrotic syndrome. Orange-tinged urine may indicate other conditions such as dehydration, liver disease, or the presence of certain medications or foods.
B. Hypertension
- Hypertension is not a common manifestation of nephrotic syndrome. However, it can occur in some cases due to the retention of sodium and water, which can lead to fluid overload and increased blood pressure.
C. Periorbital edema
- This is a classic manifestation of nephrotic syndrome. Periorbital edema, or swelling around the eyes, is often one of the initial signs observed in children with nephrotic syndrome due to the loss of protein in the urine, leading to fluid accumulation in the tissues.
D. Polyuria
- Polyuria, or increased urine output, is not typically associated with nephrotic syndrome. Instead, children with nephrotic syndrome may experience oliguria or normal urine output, depending on the severity of renal involvement and fluid balance.
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