A nurse is assisting with the plan of care for a client who has burns to his lower extremities. Which of the following actions should the nurse include in the plan?

Cleanse the most contaminated wounds first.

Use hydrogen peroxide for wound cleaning

Perform dressing changes every other day.

Apply dressings with sterile gloves

Answer and Explanation

The Correct Answer is D

Rationale:

A. Cleanse the most contaminated wounds first: Wound care should begin with the cleanest area and progress to the most contaminated to reduce the risk of cross-contamination. Starting with the dirtiest wounds may spread infection to cleaner sites.

B. Use hydrogen peroxide for wound cleaning: Hydrogen peroxide can damage healthy tissue and delay healing. It is generally not recommended for burn wound care due to its cytotoxic effects on granulating tissue.

C. Perform dressing changes every other day: Dressing frequency depends on the type of burn, wound condition, and healthcare provider's orders. Some burn wounds require daily or even more frequent changes to prevent infection and promote healing.

D. Apply dressings with sterile gloves: Sterile technique is critical in burn care to prevent infection. Using sterile gloves during dressing application ensures the wound is protected from external contaminants during a vulnerable healing phase.

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Correct Answer is A

Explanation

Rationale:

A. "I feel that soon everything will be ok.": This is a covert statement because it sounds hopeful but may actually reflect a decision to end one’s life. Sudden calmness or vague optimism in someone with a history of major depressive disorder can indicate suicidal planning and should prompt immediate follow-up.

B. "I just cannot take this anymore.": This is an overt expression of emotional distress and hopelessness. While serious, it clearly communicates the client's feelings and is more direct than covert.

C. "My family would be better off if I was dead.": This is an overt suicidal statement suggesting that the client believes their death would benefit others. It requires immediate attention and suicide risk assessment.

D. "I do not want to be here anymore.": This is another overt expression that directly indicates a desire to no longer live or be present. It reflects suicidal ideation and needs urgent intervention but is not considered covert.

A. Orientation B. Blood pressure C. Temperature D. WBC count E. Hallucinations

Correct Answer is ["A","B","C","E"]

Explanation

Rationale:

• Orientation: The client was previously disoriented to time and place, thinking it was 1975 and they were at home. On Day 2, they are alert and fully oriented. This improvement shows enhanced neurological and cognitive status.

• Blood pressure: On Day 1, the client’s BP was 88/50 mm Hg, which indicated hypotension. By Day 2, the BP improved to 132/86 mm Hg. This indicates stabilization of cardiovascular function and better perfusion.

• Temperature: The fever rose to 39.1°C on Day 1 but decreased to 37.7°C on Day 2. This drop suggests the client is responding to treatment and the infectious process is being controlled.

• Hallucinations: On Day 1, the client reported spiders crawling on them, indicating delirium. On Day 2, they deny hallucinations. This improvement shows resolving infection or neuroinflammation.

• WBC count: The WBC count of 14,000/mm³ remains elevated above the normal range and was only assessed on Day 1. Without follow-up labs, it does not indicate improvement.

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A nurse is assisting with the plan of care for a client who has burns to his lower extremities. Which of the following actions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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