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.
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Applying wet-to-dry dressings is an outdated and inappropriate practice for burn wound care.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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A
Rationale:
A) Place the client in a room with negative airflow: Disseminated herpes zoster (shingles) requires airborne precautions because the virus can become aerosolized. A room with negative airflow helps prevent the spread of the virus to other areas, protecting healthcare workers and other patients from infection.
B) Remove isolation gown after leaving the client's room: Isolation gowns should be removed before leaving the client's room to prevent the spread of contaminants to other areas. This intervention is important for infection control but is not specific to the requirement for negative airflow in cases of disseminated herpes zoster.
C) Apply ketoconazole to the lesions three times per day: Ketoconazole is an antifungal medication and is not used for treating herpes zoster, which is caused by a viral infection. Antiviral medications, such as acyclovir, are appropriate for treating herpes zoster lesions.
D) Provide the client with eye protection for ultraviolet B light therapy: Eye protection is necessary during UVB light therapy to protect the eyes, but UVB light therapy is not a standard treatment for disseminated herpes zoster. The priority intervention is to prevent the spread of the infection by using a negative airflow room.
Correct Answer is D
Explanation
Answer: D. A client whose medications to manage Parkinson's disease are no longer effective.
Rationale:
A) A client who is newly diagnosed with type 1 diabetes mellitus and cannot afford insulin:
While this client has a significant medical issue, the primary concern here is financial rather than palliative. Palliative care focuses on providing relief from symptoms and improving quality of life for those with serious illnesses. Addressing the client's financial issues might involve social services or community resources rather than palliative care.
B) A client who has Meniere's disease and cannot safely ambulate due to vertigo:
Meniere's disease, while debilitating, may not necessarily require palliative care unless the symptoms are severely impacting the client's quality of life in a way that is not manageable with current treatments. Palliative care could be considered if the disease is severely limiting function and other supportive care is needed.
C) A client who had a stroke and cannot eat or drink without choking:
This client is experiencing a significant functional impairment due to the stroke, which might benefit from rehabilitative services rather than palliative care. Palliative care would be more appropriate if the client's condition is progressive, severe, and not responsive to treatment, leading to a focus on comfort and quality of life.
D) A client whose medications to manage Parkinson's disease are no longer effective:
When medications for Parkinson's disease are no longer effective, the client may be experiencing advanced symptoms and a decline in quality of life. Palliative care can provide symptom management, support, and enhance the client's quality of life when conventional treatments are no longer effective in controlling symptoms.
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