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 B
Explanation
Choice A reason: Using a 20-gauge needle for injections in a 3-month-old infant is not appropriate as it is too large. A smaller gauge needle should be used to minimize pain and tissue trauma.
Choice B reason: Providing a pacifier coated with an oral sucrose solution prior to the injections is an evidence-based practice to reduce pain in infants. The sweet taste of sucrose has a soothing effect and can help to distract the infant from the discomfort of the injection.
Choice C reason: Injecting immunizations into the deltoid muscle is not recommended for a 3-month-old infant as their muscle mass is not yet fully developed. The anterolateral thigh is the preferred site for intramuscular injections in infants.
Choice D reason: Applying eutectic mixture of local anesthetics (EMLA) cream immediately before the injections can help to numb the skin and reduce pain. However, it needs to be applied at least one hour before the procedure to be effective.
Correct Answer is C
Explanation
Choice A reason: Avoiding the removal of the cream prior to the procedure is important, but it does not specify when or how the cream should be applied, which is crucial for its effectiveness.
Choice B reason: Rubbing the cream into the skin is not recommended as it should be applied as a thick layer and covered with an occlusive dressing to ensure proper absorption and numbing effect.
Choice C reason: Applying the cream 1 hour before the procedure allows enough time for the lidocaine and prilocaine to take effect, providing adequate local anesthesia for the insertion of the IV catheter.
Choice D reason: Washing the site with alcohol prior to applying the cream is necessary to clean the area, but it is not the action that addresses the primary goal of numbing the site for the procedure.
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