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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Hyperpyrexia, or extremely high fever, is a common symptom of acetylsalicylic acid (aspirin) poisoning. The body's response to the toxic levels of aspirin can lead to an elevated temperature as part of a systemic inflammatory response.
Choice B reason: Jaundice is not a typical symptom of acute acetylsalicylic acid poisoning. It is more commonly associated with liver conditions that cause an increase in bilirubin levels.
Choice C reason: Neck vein distention is not a common finding in acetylsalicylic acid poisoning. It is often seen in conditions that cause increased pressure in the venous system, such as heart failure.
Choice D reason: Polyuria, or excessive urination, is not a direct symptom of acetylsalicylic acid poisoning. While changes in urination can occur due to renal involvement, hyperpyrexia is a more immediate concern.
Correct Answer is D
Explanation
Choice A reason: Genital herpes simplex virus is a common sexually transmitted infection, but it is not nationally notifiable. It is managed with antiviral medications and patient education.
Choice B reason: Bacterial vaginosis is a condition caused by an imbalance of bacteria in the vagina and is not classified as a sexually transmitted infection. It is not nationally notifiable.
Choice C reason: Trichomoniasis is a sexually transmitted infection caused by a parasite. While it is common and treatable, it is not nationally notifiable.
Choice D reason: Gonorrhea is a sexually transmitted bacterial infection that is nationally notifiable. Public health departments track cases of gonorrhea to monitor and control outbreaks.
Choice E reason: Human papillomavirus (HPV) is the most common sexually transmitted infection and can lead to health problems like genital warts and cancers. However, it is not nationally notifiable.
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