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?
Use hydrogen peroxide for wound cleaning.
Perform dressing changes every other day.
Cleanse the most contaminated wounds first,
Apply dressings with sterile gloves.
The Correct Answer is D
A. Using hydrogen peroxide for wound cleaning is not recommended as it can cause tissue damage and delay healing.
B. Burn dressings should typically be changed more frequently, often at least once per day, depending on the type and severity of the burn and the type of dressing used. Delaying dressing changes could increase the risk of infection.
C. In wound care, the nurse should cleanse the least contaminated wounds first to prevent spreading microorganisms from more contaminated areas to cleaner areas. This reduces the risk of cross-contamination and infection. For burns, starting with the cleanest areas ensures a safer wound management process.
D. Applying dressings with sterile gloves is essential to maintain a sterile environment and reduce the risk of infection, especially in clients with burns who are at high risk for infection due to compromised skin integrity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
All of the listed actions can be part of evaluating the effectiveness of a performance improvement program, but identifying data collection methods is the most specific to evaluating the outcomes of the program.
Therefore, the nurse should identify data collection methods to evaluate the effectiveness of the program. Reviewing the facility's policy and procedure manual, defining the problem, and performing chart audits are all important steps in the performance improvement process, but they do not specifically address the evaluation of the program's effectiveness.
Correct Answer is D
Explanation
Effective communication with the client is crucial to understand their desires and provide appropriate care. When faced with a language barrier, it is important to use professional interpreter services to ensure accurate and clear communication. By requesting an interpreter, the nurse can obtain a clear understanding of the client's wishes and concerns regarding leaving AMA.
Without clear communication with the client, it is not appropriate to assume that the partner can make decisions on their behalf or sign an AMA form. It is important to directly ascertain the client's wishes.
Discharging the client without understanding their wishes and providing appropriate education or interventions could potentially put the client at risk. It is necessary to have a clear understanding of the client's desires before taking any action.
Asking the partner to reiterate the consequences of leaving AMA to the client: While educating the client and their partner about the consequences of leaving AMA is important, it is not sufficient in this situation. The nurse needs to directly communicate with the client to understand their wishes and concerns.
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