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 B
Explanation
Rationale:
A. 1/2 cup of corn: While corn contains some folate, the amount is relatively low compared to legumes and leafy greens. It is not considered one of the best sources of folic acid for meeting the increased demands of early pregnancy.
B. 1/2 cup of cooked lentils: Lentils are among the richest natural sources of folic acid, providing a significant portion of the recommended daily intake. They are especially beneficial during early pregnancy to help prevent neural tube defects in the developing fetus.
C. 1 fried egg: Eggs provide a small amount of folate but are not a primary source. Although eggs offer other important nutrients during pregnancy, they do not meet the body’s high folic acid needs at 8 weeks gestation.
D. 1 slice of toast: Most bread products in some regions are fortified with folic acid, but the quantity in a single slice is minimal. While it can contribute to daily intake, it is not as concentrated a source as legumes like lentils.
Correct Answer is B
Explanation
Rationale:
A. "I will follow a full-liquid diet the day before the procedure.": Clients are typically instructed to follow a clear-liquid, not full-liquid, diet the day before a colonoscopy. Clear liquids like broth, gelatin, and clear juice help ensure the colon is clean for optimal visualization.
B. "I'll have my friend drive me home after the procedure.": Sedation is usually administered during a colonoscopy, which impairs alertness and coordination. Having a responsible adult to drive the client home is necessary and reflects appropriate understanding of post-procedure safety.
C. "I can expect rectal bleeding for a week after the procedure”: Rectal bleeding after a colonoscopy is not expected and could indicate complications such as a perforation or polyp removal site bleeding. Any persistent or heavy bleeding should be reported immediately.
D. "This procedure will take place while I’m under general anesthesia.”: Colonoscopies are generally performed under moderate (conscious) sedation, not general anesthesia. Clients remain semi-awake but relaxed and unaware, making this statement inaccurate.
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