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. Give the dose of medication in the infant's bottle: Placing nystatin in a bottle may result in incomplete dosing, as the infant may not consume the full amount. This method also limits the medication's contact time with the affected mucosa, reducing its effectiveness.
B. Educate the caregiver to avoid breastfeeding: Breastfeeding should not be avoided unless the mother has signs of candidiasis on the breast. Instead, both mother and infant should be treated simultaneously if either shows symptoms to prevent reinfection.
C. Administer the medication before the infant's feeding: Administering nystatin before feeding may cause the medication to be washed away by milk, decreasing mucosal contact time. It is generally recommended after feeding to ensure prolonged exposure to the mucosa.
D. Distribute the medication on the infant's oral mucosa: Applying the suspension directly to the affected areas allows the antifungal to coat the mucosa thoroughly, maximizing effectiveness. It is the preferred method to treat oral candidiasis in infants.
Correct Answer is ["1.5"]
Explanation
Calculation:
Desired dose = 60 mg.
Available concentration = 50 mg/1.25 mL.
- Calculate the volume in milliliters (mL) to administer.
Volume (mL) = Desired dose (mg) / (Available concentration (mg) / Available volume (mL))
= 60 mg / (50 mg / 1.25 mL)
= 60 mg / 40 mg/mL
= 1.5 mL.
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