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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason: Inserting a nasal swab to observe the fluid is contraindicated, as it can introduce infection or increase intracranial pressure. The fluid can be tested for glucose or halo sign to confirm cerebrospinal fluid (CSF) leakage.

Choice B Reason: Suctioning the nose gently with a bulb syringe is also contraindicated, as it can create negative pressure and increase CSF leakage or cause meningitis.

Choice C Reason: This is the correct answer because allowing the drainage to drip onto a sterile gauze pad can prevent contamination and facilitate observation of the amount and characteristics of the fluid.

Choice D Reason: Inserting sterile packing into the nares is not recommended, as it can obstruct the drainage and increase intracranial pressure or infection risk.

A. Encourage coughing and deep breathing B. Position the patient with knees and hips flexed C. Perform nursing interventions once an hour to provide rest periods D. Keep the head of the bed elevated to 30 degrees

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because encouraging coughing and deep breathing can increase intracranial pressure (ICP), which is the pressure inside

the skull that can affect brain function. Coughing and deep breathing can increase blood flow and oxygen demand to the brain, which can worsen cerebral edema. The nurse should suction the patient as needed and maintain a patent airway.

Choice B Reason: This is incorrect because positioning the patient with knees and hips flexed can increase ICP by reducing venous drainage from the head. The nurse should position the patient with neck and body in alignment and avoid extreme flexion or extension of any joints.

Choice C Reason: This is incorrect because performing nursing interventions once an hour can disturb the patient's sleep and increase ICP by stimulating brain activity. The nurse should cluster nursing interventions and provide quiet and dark environment to promote rest and reduce stress.

Choice D Reason: This is correct because keeping the head of the bed elevated to 30 degrees can decrease ICP by facilitating venous drainage from the head and reducing cerebral blood volume. The nurse should monitor the patient's blood pressure and pulse to ensure adequate cerebral perfusion.

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A nurse is preparing a client with extensive burns for hydrotherapy. What is the priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A patient who is unconscious after a head injury has cerebral edema. Which nursing intervention will be included in the plan of care?

Correct Answer is D

Explanation

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