A nurse is preparing to provide hydrotherapy for a client who has a burn wound. Which of the following actions should the nurse plan to take?

Use fingers to remove loose tissue.

Open small blisters to expose air.

Wash the burn with a mild soap.

Apply wet-to-dry dressing.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Using fingers to remove loose tissue is not an appropriate action for the nurse to take when providing hydrotherapy for a burn wound. This action can cause further trauma to the wound and increase the risk of infection.

Choice B rationale:

Opening small blisters to expose air is contraindicated in burn wound management. The blister roof provides a natural barrier against infection, and puncturing them increases the risk of infection and delays the healing process.

Choice C rationale:

The correct answer is to wash the burn with a mild soap. Cleaning the burn wound with mild soap and water helps remove debris and minimize the risk of infection without causing additional damage.

Choice D rationale:

Applying wet-to-dry dressings is an outdated and inappropriate practice for burn wound care. Wet-to-dry dressings can be painful, disrupt wound healing, and increase the risk of infection. Modern burn wound care focuses on maintaining a moist environment to support optimal healing.

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Correct Answer is A

Explanation

Choice A rationale:
The nurse should instruct the client to place cellular phones on the ear opposite the side of the pacemaker to minimize the risk of electromagnetic interference. Although the risk of interference is low with modern pacemakers, it is still a precautionary measure. Placing the phone on the ear opposite the pacemaker reduces the likelihood of any potential electromagnetic interaction.
Choice B rationale:
The instruction in choice B, "Avoid showering for the first 2 weeks following surgery,”. is not appropriate. There is no need for the client to avoid showering after pacemaker insertion. In fact, maintaining good hygiene is essential to prevent infection at the incision site. The client can take a shower, but they should avoid soaking the incision area and patting it dry afterward.
Choice C rationale:
The instruction in choice C, "Avoid heavy lifting for 1 week following insertion,”. is not the best option. The recommended timeframe to avoid heavy lifting after a pacemaker insertion is usually around 4 to 6 weeks. This duration allows the surgical site to heal properly and reduces the risk of dislodging the pacemaker leads or causing damage.
Choice D rationale:
The instruction in choice D, "Stand at least 2 feet away while using a microwave,”. is not directly related to pacemaker care. While it is generally recommended to maintain a safe distance from microwaves during use, this instruction is not specific to clients with pacemakers.

A. Fruity smelling breath. B. Painful urination. C. Hypotension. D. Lethargy.

Correct Answer is D

Explanation

Choice A rationale:
Fruity-smelling breath is associated with diabetic ketoacidosis (DKA), which is not the expected manifestation of chronic kidney disease (CKD). DKA occurs in uncontrolled diabetes and is not the priority for this client.
Choice B rationale:
Painful urination is not a typical clinical manifestation of chronic kidney disease. It is more commonly associated with urinary tract infections or other urological issues.
Choice C rationale:
Hypotension may occur in end-stage kidney disease, but it is not specific to chronic kidney disease and is not a priority in this scenario.
Choice D rationale:
Lethargy is a common clinical manifestation of chronic kidney disease due to the accumulation of waste products in the blood, leading to uremia. It is a priority as it indicates the progression of the disease and the need for close monitoring and intervention.

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A nurse is preparing to provide hydrotherapy for a client who has a burn wound. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has a newly inserted permanent pacemaker. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who has chronic kidney disease. The nurse should expect the client to have which of the following clinical manifestations?

Correct Answer is D

Explanation

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