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
To accurately assess the client's respirations, the nurse should observe the movements of the client's chest wall. This can be done by visually inspecting the rise and fall of the chest or by placing a hand on the client's chest to feel the movements. This allows the nurse to assess the depth, rhythm, and effort of the client's breathing. I
It is important to observe the client's respirations without informing them, as this may cause the client to alter their breathing pattern consciously.
Counting the client's respirations for a full minute (rather than 15 seconds) provides a more accurate measurement.
Placing the client in a supine position may not be necessary for assessing respirations, as it is primarily focused on observing the chest movements.
Correct Answer is B
Explanation
This response allows the nurse to actively listen to the client, gain a better understanding of their concerns and reasons behind wanting to stop treatment, and open the door for a more in-depth conversation. It demonstrates a non-judgmental approach and creates an opportunity for the client to express their fears, concerns, or any other factors influencing their decision.
"I would feel the same way if I were you." This response reflects the nurse's personal opinion and may not accurately represent the client's thoughts or feelings. It does not encourage the client to explore their own feelings or provide an opportunity for open communication.
"Why do you think that would be a good choice?" This response may come across as confrontational and judgmental, potentially making the client defensive or shutting down communication. It does not facilitate a therapeutic conversation or encourage the client to express their emotions and concerns openly.
"You'll be cancer-free after you complete your treatments." This response may oversimplify the client's situation or offer false reassurance. It is important to acknowledge the client's feelings and concerns while providing accurate information and support, rather than making unrealistic promises about treatment outcomes.
The nurse should approach the client's expression of wanting to stop treatment with empathy, active listening, and an open mind to provide the necessary support, education, and resources to help the client make informed decisions about their healthcare.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today