A nurse is reinforcing teaching with a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include?

"Use a moisturizer on your skin after cleaning."

"Rub your skin firmly when cleaning."

"Wash your skin daily with hot water.”

"Allow your skin to air dry after bathing.”

Answer and Explanation

The Correct Answer is A

A. "Use a moisturizer on your skin after cleaning."
Moisturizers help maintain skin hydration and barrier function, reducing the risk of breakdown and infection.

B. "Rub your skin firmly when cleaning."
This can cause microabrasions and increase the risk of skin breakdown and infection.

C. "Wash your skin daily with hot water.”
Hot water can dry out the skin and compromise the skin barrier, increasing infection risk.

D. "Allow your skin to air dry after bathing.”
Patting the skin dry is better than air drying, which can lead to excessive dryness and irritation.

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Correct Answer is B

Explanation

A. Perform hourly neurological assessments on the client:
Important, but not the first action. Neurological symptoms may improve with oxygenation.

B. Administer oxygen to the client at 100%:
CO binds to hemoglobin with a higher affinity than oxygen. 100% oxygen displaces CO and is the priority intervention to reduce hypoxia.

C. Institute seizure precautions for the client:
Useful if the client becomes neurologically compromised, but not the priority over oxygenation.

D. Provide ondansetron IV to the client for nausea:
Nausea can occur in CO poisoning, but treating hypoxia is the priority.

A. Administering pain medication B. Providing emotional support to the client C. Applying a topical burn ointment D. Assessing the client's airway and breathing

Correct Answer is D

Explanation

A. Administering pain medication
Pain control is important but secondary to ensuring the airway is clear.

B. Providing emotional support to the client
While necessary, emotional support is not an immediate priority during the acute phase of burn care.

C. Applying a topical burn ointment
This is appropriate after stabilization, not before airway and breathing are assessed.

D. Assessing the client's airway and breathing
Airway and breathing take top priority in burn clients, especially if the burns involve the face, neck, or chest. Inhalation injury, edema, or airway obstruction can be life-threatening and must be assessed immediately.

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A nurse is reinforcing teaching with a client about maintaining skin integrity to decrease the risk of infection. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who sustained severe carbon monoxide (CO) poisoning after being trapped in a burning building. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

When prioritizing the care of a client with burns, which intervention should the nurse implement first?

Correct Answer is D

Explanation

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