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 A
Explanation
Clients in the manic phase often exhibit inflated self-esteem, a sense of superiority, and grandiose thinking. They may have unrealistic beliefs about their abilities, accomplishments, or importance.
Hypersomnia, or excessive sleepiness, is not typically associated with the manic phase of bipolar disorder. Instead, individuals in the manic phase often experience a decreased need for sleep and may go for long periods with little or no sleep.
Blunted affect refers to a lack of emotional expression or reduced intensity of emotional responses. It is more commonly associated with depressive episodes of bipolar disorder rather than the manic phase.
Slurred speech is not a typical finding in the manic phase of bipolar disorder. However, individuals in the manic phase may exhibit rapid or pressured speech, talking excessively, rapidly switching topics, or having difficulty keeping up with their own thoughts.
Correct Answer is D
Explanation
a.This is not recommended. The central tip of the finger is more sensitive and has more nerve endings, which can cause more pain. The recommended site for blood glucose testing is the side of the fingertip, as it is less sensitive and provides an adequate blood sample.
b. While it is not necessary to wear sterile gloves for routine capillary blood glucose monitoring, it is important to ensure that the nurse's hands are clean. Wearing clean gloves helps maintain infection control practices.
c. After puncturing the selected site, the nurse should gently squeeze the finger to create a small drop of blood. The first drop of blood should be wiped away, and subsequent drops should be used for the glucose test. This ensures that the sample is fresh and not contaminated with tissue fluid.
d.Keeping the finger in a dependent position (hanging down) helps improve blood flow to the fingertip, making it easier to obtain a sufficient blood sample. This can help ensure an accurate glucose reading.
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