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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Leukorrhea refers to the increased vaginal discharge that is common during pregnancy. It is usually thin, white, or milky in appearance and is caused by hormonal changes and increased blood flow to the vaginal area. Informing the client about this normal pregnancy symptom can help alleviate concerns and promote reassurance.

Facial swelling, especially during the first trimester, is not a common discomfort experienced in early pregnancy. It can be a symptom of other underlying medical conditions, such as preeclampsia, which should be evaluated by a healthcare provider.

While gastrointestinal changes and bowel irregularities can occur during pregnancy, including constipation, diarrhea is not typically associated with the first trimester. Persistent or severe diarrhea should be assessed by a healthcare provider as it can indicate an underlying issue or infection.

Burning or discomfort during urination is not a typical discomfort of the first trimester. It is more commonly associated with urinary tract infections (UTIs) or other urinary issues. If a client experiences these symptoms, they should be evaluated by a healthcare provider for appropriate diagnosis and treatment.

A. "It is for clients who are given 6 months or less to live." B. "It includes restriction of nutritional support." C. "It enhances quality of life by promoting comfort." D. "It is for clients who have a terminal illness."

Correct Answer is C

Explanation

Palliative care is an approach to care that focuses on improving the quality of life for individuals with serious or life-threatening illnesses. It aims to provide relief from pain, symptoms, and stress, rather than focusing solely on curing the underlying disease. Palliative care can be provided alongside curative treatments and is not limited to clients with a specific life expectancy.

It does not involve the restriction of nutritional support but rather aims to address the overall physical, emotional, and spiritual needs of the client.

While palliative care may be provided to clients with terminal illnesses, it is not exclusive to them, as it can be initiated at any stage of a serious illness.

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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?

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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?