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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Store ready-to-feed formula at room temperature for up to 4 hours.": Ready-to-feed formula should be used promptly or refrigerated if not used immediately. Leaving it at room temperature for up to 4 hours increases the risk of bacterial growth and contamination.
B. "Warm the bottle of formula by immersing it in a container of warm tap water.": This is a safe and recommended method to gently warm formula without overheating or creating hot spots that could burn the infant’s mouth.
C. "Keep open cans of concentrated formula uncovered and refrigerated.": Open cans of concentrated formula should always be covered to prevent contamination and should be refrigerated promptly after opening.
D. "Discard any formula left in the bottle within 2 hours after beginning feeding.": Formula left in the bottle after feeding should be discarded within 1 to 2 hours to prevent bacterial growth that can cause illness in the infant. This practice helps ensure feeding safety.
Correct Answer is B
Explanation
Rationale:
A. "I will irrigate the colostomy every day.": Colostomy irrigation is used for descending or sigmoid colostomies to regulate bowel movements. It is not recommended for ascending colostomies because the stool is too liquid and unpredictable for effective irrigation.
B. "I will notify my doctor if the stoma starts to look purple.": A healthy stoma should be pink or red and moist. A purple or dusky appearance suggests compromised blood flow or ischemia and should be reported to the provider immediately as it may indicate a serious complication.
C. "I should expect my stool to be formed.": Stool from an ascending colostomy is generally liquid to semi-liquid due to the location in the digestive tract. Formed stool is more typical of descending or sigmoid colostomies, not ascending ones.
D. "I will no longer be able to eat nuts.": While some clients may choose to avoid certain foods based on personal tolerance, there is no absolute dietary restriction against nuts for colostomy clients unless otherwise advised.
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