A patient with burn wounds is undergoing ROM therapy but resists due to pain. What is the nurse's best response?

Explain ROM therapy

Delay therapy until pain improves

Manage pain prior to therapy

Stop therapy permanently

Answer and Explanation

The Correct Answer is C

A. Explain ROM therapy: Educating the patient about the purpose and benefits of range-of-motion (ROM) therapy is important for cooperation and understanding. However, patient education alone does not address the immediate barrier of pain, which can prevent participation and limit the effectiveness of therapy.

B. Delay therapy until pain improves: Postponing therapy may reduce immediate discomfort but can lead to joint stiffness, contractures, and decreased functional outcomes. Burn rehabilitation requires timely, consistent ROM exercises to maintain mobility, so delaying therapy is not ideal.

C. Manage pain prior to therapy: Administering analgesics before ROM exercises allows the patient to participate more comfortably and effectively. Preemptive pain control reduces muscle guarding, facilitates full joint movement, and improves compliance, directly supporting the goal of preserving function and preventing contractures.

D. Stop therapy permanently: Discontinuing ROM therapy permanently would result in progressive joint contractures, decreased mobility, and long-term functional deficits. Pain management strategies should be used to enable continued participation rather than abandoning therapy altogether.

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Correct Answer is A

Explanation

A. Instruct the patient to keep the catheter clean: Peritonitis is the most common complication of peritoneal dialysis and is usually caused by contamination at the catheter site. Maintaining strict aseptic technique during catheter care and handling dialysis equipment minimizes the risk of bacterial entry into the peritoneal cavity, making this intervention essential for prevention.

B. Position patient supine: While supine positioning may aid in comfort or initial dialysis fluid instillation, it does not prevent infection. Positioning alone has no impact on the risk of peritonitis.

C. Encourage patient to increase fluid intake: Adequate hydration supports overall renal function and helps maintain intravascular volume, but it does not directly reduce the risk of peritoneal infection. Fluid intake is supportive rather than preventive for peritonitis.

D. Measure abdominal girth: Monitoring abdominal girth helps detect fluid retention, bloating, or early complications such as dialysate leakage, but it does not prevent infection. This intervention is observational rather than prophylactic.

A. Instill normal saline into the nose to clear any possible obstructions. B. Use a sterile dressing to collect the nasal drainage and send it for testing C. Apply ice packs to the nose to reduce swelling and drainage. D. Instruct the patient to cough to clear nasal passages.

Correct Answer is B

Explanation

A. Instill normal saline into the nose to clear any possible obstructions: Flushing the nasal passages could increase intracranial pressure or dislodge clots, potentially worsening a skull fracture or causing CSF leakage. This intervention is unsafe in suspected basilar skull fractures.

B. Use a sterile dressing to collect the nasal drainage and send it for testing: Raccoon eyes and clear rhinorrhea suggest a possible basilar skull fracture with cerebrospinal fluid (CSF) leakage. Collecting drainage on a sterile dressing and testing for glucose or beta-2 transferrin confirms the presence of CSF. This intervention protects the patient from infection and provides diagnostic information safely.

C. Apply ice packs to the nose to reduce swelling and drainage: While ice may reduce swelling in minor facial injuries, it does not address the risk of CSF leakage or confirm the diagnosis of a skull fracture. Applying ice does not take priority over diagnostic assessment and infection prevention.

D. Instruct the patient to cough to clear nasal passages: Coughing increases intracranial pressure and may exacerbate CSF leakage or worsen the fracture. Patients with suspected basilar skull fractures should avoid actions that increase pressure in the skull.

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A patient with burn wounds is undergoing ROM therapy but resists due to pain. What is the nurse's best response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has returned to the medical surgical unit after receiving peritoneal dialysis. Which of the following nursing interventions should the nurse implement to prevent peritonitis?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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