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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

c. New onset of hearing loss.

When collecting data from a client who is receiving gentamicin via IV infusion, the nurse should identify new onset of hearing loss as an adverse eﬀect of the treatment¹. Gentamicin can cause vestibulocochlear nerve damage, which can aﬀect hearing and balance¹.

A. Support the extremity above and below each joint during the exercises. B. Repeat each exercise movement 10 times. C. Position the bed at mid-thigh level. D. Move each joint just past the point of resistance.

Correct Answer is A

Explanation

This is an essential instruction for performing passive ROM exercises safely and effectively. Supporting the extremity above and below each joint helps to prevent injury and provides stability during the exercise. This technique also helps to minimize discomfort and maintain proper alignment of the joint.

Repeat each exercise movement 10 times: This instruction does not provide sufficient guidance on the number of repetitions and may be too general. The number of repetitions will depend on the client's condition and tolerance.

Position the bed at mid-thigh level: This instruction is not necessary for performing passive ROM exercises and may not be feasible in all settings.

Move each joint just past the point of resistance: This instruction can be harmful and may cause injury or pain. The nurse should encourage the family to move the joint gently and smoothly, within the range of motion that is comfortable for the client.

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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?

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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?