A nurse is planning to complete dressing changes for an adolescent who has multiple burn injuries. Which of the following interventions addresses the greatest risk to the client?
Apply tepid water to the old dressings before removal.
Check the wound sites for manifestations of infection.
Perform passive range-of-motion exercises during the dressing change.
Adjust the room temperature to 33°C (91.4°F).
The Correct Answer is B
Choice A reason: Applying tepid water to the old dressings can help with their removal and may reduce discomfort, but it does not address the greatest risk to the client, which is infection.
Choice B reason: Checking the wound sites for manifestations of infection is crucial as burn injuries compromise the skin's protective barrier, making the client highly susceptible to infections. Infections can lead to further complications and delay healing.
Choice C reason: Performing passive range-of-motion exercises is important for maintaining joint mobility and preventing contractures in burn patients, but it is not the primary intervention for addressing the greatest risk of infection.
Choice D reason: Adjusting the room temperature to 33°C (91.4°F) can create a more comfortable environment for the burn patient and prevent hypothermia, but it is not directly related to the prevention of infection, which is the greatest risk.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Introducing popcorn as a healthy snack at 12 months of age is not recommended due to the risk of choking. Popcorn is a choking hazard for young children and should be avoided until they are older.
Choice B reason: Providing 36 oz of milk per day to a toddler may be excessive and can lead to iron deficiency anemia due to the displacement of other iron-rich foods. The American Academy of Pediatrics recommends 16-24 oz of milk per day for toddlers.
Choice C reason: Offering 8 to 10 oz of juice per day to a preschooler exceeds the American Academy of Pediatrics' recommendation of limiting juice to 4-6 oz per day for children 1-6 years old to prevent dental caries and ensure they consume more whole fruits.
Choice D reason: Encouraging a 15-year-old to increase calcium intake is appropriate as adolescence is a critical period for bone development. Adequate calcium intake supports optimal bone growth and density, helping to prevent osteoporosis later in life.
Correct Answer is D
Explanation
Choice A reason: Contact precautions are used for infections that spread by direct or indirect contact with the patient or the patient's environment. While important, they are not the primary precaution for pertussis.
Choice B reason: Airborne precautions are used for diseases that are transmitted through the air over long distances, such as tuberculosis. Pertussis does not typically require airborne precautions.
Choice C reason: Protective precautions are used to protect immunocompromised patients from being infected by others. This is not applicable for a child with pertussis, who is the source of infection.
Choice D reason: Droplet precautions are used for diseases that are transmitted through large droplets expelled during coughing, sneezing, or talking. Pertussis, also known as whooping cough, is primarily spread through respiratory droplets, making droplet precautions the appropriate choice.
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