A client has partial thickness burns to both arms. After medicating the client with an opioid analgesic, the practical nurse (PN) changes the sterile dressings. Which action is most important for the PN to implement before applying silver sulfadiazine cream to the burn lesions?
Apply the cream to the sterile dressings using a sterile tongue blade.
Remove the previous layer of medication using sterile normal saline.
Open all the supplies before donning sterile gloves.
Evaluate the client's response to the medications.
The Correct Answer is B
A. Apply the cream to the sterile dressings using a sterile tongue blade:
Silver sulfadiazine is applied directly to the burn, not to the dressing.
B. Remove the previous layer of medication using sterile normal saline:
Old cream must be removed to ensure medication effectiveness and prevent debris accumulation.
C. Open all the supplies before donning sterile gloves:
Helps maintain sterile field but is not the most important step before application.
D. Evaluate the client's response to the medications:
Pain relief should be assessed, but cleansing is the critical preparation step before new application.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Approach the individuals involved and ask them to stop:
Immediate intervention stops the breach of confidentiality and maintains client privacy.
B. Tell the client of the UAP's concern for him:
Would further violate confidentiality and harm trust.
C. Try not to listen to the conversation since it is confidential:
Passive approach; does not stop the breach.
D. Write an incident report and submit it to the unit manager:
May be needed afterward, but first action is to stop the conversation.
Correct Answer is A
Explanation
A. Use normal saline to rinse the client's mouth: Normal saline is safe, non-irritating, and helps maintain oral mucosa integrity.
B. Avoid contact with the roof of the mouth: Unnecessary; oral care includes cleaning all oral surfaces gently.
C. Lower the head of the bed to 30 degrees: This increases aspiration risk; the head should be elevated or the client positioned side-lying.
D. Don sterile gloves prior to performing oral care: Clean gloves are sufficient; sterile gloves are not required.
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