A nurse is preparing a client with extensive burns for hydrotherapy. What is the priority action by the nurse?
Educate the client about the therapy
Provide analgesics after therapy ends
Provide analgesics before therapy begins
Ensure there are clean supplies
The Correct Answer is C
Choice A Reason: Educating the client about the therapy is an important action by the nurse, but not the priority one. The nurse should explain the purpose, procedure, benefits, and risks of hydrotherapy to the client before starting it, but only after ensuring their comfort and pain relief.
Choice B Reason: Providing analgesics after therapy ends is not enough, as the nurse should provide them before and during therapy as well. Hydrotherapy involves cleansing and debriding of burn wounds with water jets or whirlpools, which can be very painful and stressful for the client.
Choice C Reason: This is the correct choice. Providing analgesics before therapy begins is the priority action by the nurse, as it reduces pain and anxiety for the client and facilitates wound healing. The nurse should assess the client's pain level and administer appropriate analgesics at least 30 minutes before hydrotherapy.
Choice D Reason: Ensuring there are clean supplies is an essential action by the nurse, but not the priority one. The nurse should use sterile or clean equipment and solutions for hydrotherapy to prevent infection and contamination of burn wounds, but only after ensuring their comfort and pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Soft pasty stool is normal for a transverse colostomy, as the stool has not reached the sigmoid colon where most of the water is absorbed.
Choice B Reason: This is the correct answer because purple discoloration of the stoma indicates ischemia or necrosis, which can lead to infection, perforation, or sepsis. It requires urgent intervention.
Choice C Reason: Stoma is beefy red is a normal finding for a healthy stoma, as it indicates adequate blood supply and healing.
Choice D Reason: There is skin excoriation around the stoma is a common complication of a colostomy, as the stool can irritate the skin. It can be managed with proper skin care and appliance fitting.
Correct Answer is ["A","B","C"]
Explanation
Choice A Reason: This is a correct choice. Trying to avoid scratching is an advice that the nurse will provide to the client, as it prevents further damage and infection of the skin. Scratching can break the skin barrier and introduce bacteria or fungi into the wound, leading to inflammation and complications.
Choice B Reason: This is a correct choice. Applying a moist cool compress is an advice that the nurse will provide to the client, as it soothes and relieves itching and swelling. A moist cool compress can reduce inflammation and histamine release, which are responsible for allergic symptoms.
Choice C Reason: This is an incorrect choice. Using alcohol to cleanse the area is not an advice that the nurse will provide to the client, as it irritates and dries out the skin. Alcohol can strip away the natural oils and moisture from the skin, making it more prone to cracking and itching.
Choice D Reason: This is an incorrect choice. Using a wooden stick to scratch lesions is not an advice that the nurse will provide to the client, as it causes more harm than good. A wooden stick can injure or infect the skin, as well as spread the allergen or irritant to other areas.
Choice E Reason: This is a correct choice. Avoiding hot air is an advice that the nurse will provide to the client, as it aggravates itching and inflammation. Hot air can increase blood flow and histamine release, which are responsible for allergic symptoms. The client should also avoid hot water or showers, as they can have the same effect.
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