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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Related Questions
Correct Answer is C
Explanation
Choice A reason: Explaining procedures in detail to the child can be overwhelming and may not be effective, as children with autism spectrum disorder often have difficulty processing too much verbal information at once.
Choice B reason: Staying with the child for long periods of time is not specific to the care of a child with autism spectrum disorder and does not address their unique needs related to transitions or sensory processing.
Choice C reason: Introducing the child to new situations slowly is important because children with autism spectrum disorder may have difficulty with changes in routine or environment. Gradual introduction can help them adjust and reduce anxiety.
Choice D reason: Giving the child three options when making choices can be helpful, but it is not as critical as introducing new situations slowly. Too many choices can sometimes be overwhelming for children with autism spectrum disorder.
Correct Answer is B
Explanation
Choice A reason: Preparing to administer a potassium IV bolus is not typically indicated in sickle cell crisis unless there is a documented potassium deficiency. Potassium levels must be carefully monitored to avoid hyperkalemia.
Choice B reason: Providing hydration both orally and intravenously is crucial in managing sickle cell crisis. Hydration helps to reduce blood viscosity and improve circulation, which can alleviate the pain and prevent further sickling of red blood cells.
Choice C reason: Requesting a prescription for meperidine is not recommended for pain management in sickle cell crisis due to the risk of seizures and other side effects. Other pain medications, such as morphine, are preferred.
Choice D reason: Administering multiple units of platelets is not a standard treatment for sickle cell crisis. Platelet transfusion is typically reserved for patients with thrombocytopenia or active bleeding, not for sickle cell crisis.
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