A nurse is planning care for a client who has full-thickness burns on the lower extremities.
Which of the following interventions should the nurse include?
Clean the equipment in the client's room once per week.
Provide a diet of fresh fruits and vegetables for the client.
Limit visitation time for the client's children to 40 min per day.
Apply new gloves when alternating between wound care sites.
The Correct Answer is D
The nurse should apply new gloves when alternating between wound care sites.
This is to prevent cross-contamination and infection.
Choice A, cleaning the equipment in the client’s room once per week, is not an answer because it is not mentioned in the search results as an intervention for a client with full-thickness burns on the lower extremities.
Choice B, providing a diet of fresh fruits and vegetables for the client, is not an answer because it is not mentioned in the search results as an intervention for a client with full-thickness burns on the lower extremities.
Choice C, limiting visitation time for the client’s children to 40 min per day, is not an answer because it is not mentioned in the search results as an intervention for a client with full-thickness burns on the lower extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Administering IV fluids can help maintain blood flow to the kidneys and prevent acute kidney failure.
Choice B is incorrect because inserting a urinary catheter does not prevent acute kidney failure.
Choice C is incorrect because an intravenous pyelogram is a diagnostic test and does not prevent acute kidney failure.
Choice D is incorrect because beta-blocker therapy is not used to prevent acute kidney failure.
Correct Answer is A
Explanation
“The client’s capillary refill in the left toe is 6 seconds.” Capillary refill time is the time it takes for blood to return to the capillaries after pressure has been applied to the skin.
A normal capillary refill time is less than 2 seconds.
A capillary refill time of 6 seconds indicates poor blood flow to the left toe and requires immediate intervention by the nurse.
Choice B is not the correct answer because while a pain level of 7 on a scale from 0 to 10 at the operative site is concerning, it does not require immediate intervention by the nurse.
Choice C is not the correct answer because an oral temperature of 38.3° C (100.9° F) is only slightly elevated and does not require immediate intervention by the nurse.
Choice D is not the correct answer because while 100 mL of blood in a closed-suction drain may be concerning, it does not necessarily require immediate intervention by the nurse.
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