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 B

Explanation

This is done by aspirating a small amount of stomach contents and testing the pH using pH paper or a pH indicator strip. The pH of stomach contents is typically acidic (pH less than 5), indicating proper placement in the stomach.

Injecting air and listening for bubbling is not a reliable method to verify tube placement, as it can lead to complications such as pneumothorax.

Measuring gastric residual is done to assess the amount of gastric contents remaining in the stomach, but it does not confirm tube placement.

Adding food coloring to the formula is not a standard practice and does not provide reliable confirmation of tube placement.

X-ray is the gold standard method to confirm tube placement but is not typically done before every intermittent feeding unless there are concerns about tube placement

A. Report the incident to the charge nurse. B. Participate in an in-service about client confidentiality. C. Tell the staff members to stop their discussion. D. Speak to the staff members in private about client confidentiality.

Correct Answer is C

Explanation

a.While reporting the incident is important, the priority is to stop the confidentiality breach immediately to protect the client's privacy.

b.Participating in training is important for long-term education, but it does not address the immediate issue of the confidentiality breach.

c. Tell the staff members to stop their discussion: This action stops the breach immediately and protects the client's confidential information, which is the first and most crucial step.

d.Speak to the staff members in private about client confidentiality: While this is a good follow-up action to educate and prevent future breaches, the immediate need is to stop the ongoing discussion

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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?