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. Open the side flap of the sterile kit, allowing it to lie flat on the work surface: This step comes later in the process of opening a sterile field. Side flaps should be opened after the top (farthest) flap to prevent reaching over the sterile field and contaminating it.
B. Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface: Opening the closest flap first risks contaminating the sterile field by reaching over it. This flap should be opened last, after the top and side flaps are already secured.
C. Apply sterile gloves: Sterile gloves are applied after the sterile field is prepared and all supplies are organized within the sterile area. Putting them on too early may lead to contamination during field setup.
D. Open the outermost flap of the sterile kit away from the nurse's body: The first step in establishing a sterile field is to open the flap away from the body. This minimizes contamination by preventing the nurse from leaning over the sterile surface.
Correct Answer is C
Explanation
Rationale:
A. Projectile vomiting: Projectile vomiting is more commonly associated with pyloric stenosis in infants, not intussusception. While vomiting may occur in intussusception, it is typically bilious and not forceful or projectile in nature.
B. Periorbital edema: Periorbital edema is typically related to renal or allergic conditions such as nephrotic syndrome or severe allergic reactions. It is not associated with gastrointestinal issues like intussusception.
C. Stools that contain currant jelly-like mucus: Intussusception causes bowel telescoping, leading to obstruction and compromised blood flow. This results in stools containing blood and mucus, often described as “currant jelly,” which is a hallmark symptom of the condition.
D. Visible gastric peristaltic waves: Visible peristalsis is more indicative of pyloric stenosis, where there is hypertrophy of the pyloric muscle. It is not typically seen in cases of intussusception.
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