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 A

Explanation

During a mass casualty event, it is crucial for the nurse to assess and determine the acuity level (severity) and number of casualties who will be arriving at the healthcare facility. This information helps in planning and organizing resources, triaging patients based on their needs, and ensuring that appropriate care is provided to those who require immediate attention.

Delegating tasks to emergency health care specialists is a role that may be performed by a nurse in a leadership or supervisory position. However, the immediate priority for the nurse is to assess and triage incoming casualties.

Providing informational updates to members of the media is usually handled by designated spokespersons or communication specialists within the healthcare facility or incident command system. Nurses are primarily focused on patient care and should not be responsible for media communication during a mass casualty event.

Assisting in discharging stable clients to home is not directly related to the immediate response and care of casualties from a mass casualty event. The nurse's focus in such situations is primarily on the management of the incoming casualties and ensuring the availability of resources and care for those who require immediate attention.

A. Location of the identification tag on the client's body B. Cause of the client's death C. Last set of the client's vital signs D. Copy of the client's advance directives

Correct Answer is A

Explanation

a. Location of the identification tag on the client's body: This is essential information that should be included in the documentation. It ensures that the deceased person is properly identified and helps prevent any mix-ups during subsequent processes, such as transferring the body to the morgue or a funeral home.

b-While this information is important, it's typically documented by the physician on the death certificate and is not generally part of the nurse's postmortem documentation.

c-The last set of vital signs is not usually required for postmortem documentation. Postmortem documentation focuses on the condition of the body and identification rather than the final vital signs, which are often irrelevant after death.

d-Advance directives should be reviewed before death and guide the care provided, but they are not part of postmortem documentation. A copy of the client's advance directives may also be included in their medical record but is not typically included in postmortem documentation.

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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?