A nurse is assisting with the plan of care for a client who has burns to his lower extremities.
Which of the following actions should the nurse include in the plan?
Use hydrogen peroxide for wound cleaning.
Perform dressing changes every other day.
Cleanse the most contaminated wounds first,
Apply dressings with sterile gloves.
The Correct Answer is D
A. Using hydrogen peroxide for wound cleaning is not recommended as it can cause tissue damage and delay healing.
B. Burn dressings should typically be changed more frequently, often at least once per day, depending on the type and severity of the burn and the type of dressing used. Delaying dressing changes could increase the risk of infection.
C. In wound care, the nurse should cleanse the least contaminated wounds first to prevent spreading microorganisms from more contaminated areas to cleaner areas. This reduces the risk of cross-contamination and infection. For burns, starting with the cleanest areas ensures a safer wound management process.
D. Applying dressings with sterile gloves is essential to maintain a sterile environment and reduce the risk of infection, especially in clients with burns who are at high risk for infection due to compromised skin integrity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Radiation therapy can affect the taste buds, leading to a diminished or altered sense of taste.
This can result in a reduced appetite or changes in food preferences.
Loose stools and bladder infection are not commonly associated with external radiation for throat cancer. Loose stools can be a side effect of radiation therapy to the abdomen or pelvis, but it is not typically seen in throat cancer treatment.
Bladder infection is not directly related to radiation therapy, but it can occur as a complication in some individuals undergoing cancer treatment, especially if they have a compromised immune system.
Increased appetite is also not a typical finding associated with radiation therapy, as it may cause side effects such as nausea or changes in taste, which can decrease appetite
Correct Answer is A
Explanation
The nurse should remove the absorbent pads from underneath the client, place the client in a supine position with arms at the sides, close the client's eyes, and replace the client's dentures.
A pillow may be placed under the client's head for cosmetic purposes, but this is not a necessary action. High-Fowler's position is not appropriate for a deceased client.
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