The nurse is caring for a client with 40% full thickness burned total body surface area (TBSA) in the Emergency Department. The nurse is awaiting transfer to a regional burn center within 20 minutes. What is the most appropriate initial wound care management while awaiting transfer?

Gently cleanse the wounds with warm soapy water

Remove blistered skin and cover with a dry dressing

Apply saline soaked wet-to-dry dressings

Cover with a clean dry sheet to prevent hypothermia

Answer and Explanation

The Correct Answer is D

A. Gently cleanse the wounds with warm soapy water

Initial burn care focuses on preventing hypothermia and infection. Cleaning is usually performed in a controlled setting like a burn unit, not in the emergency phase.

B. Remove blistered skin and cover with a dry dressing

Blisters should not be removed in the initial phase unless they are large and tense. Removal increases the risk of infection.

C. Apply saline-soaked wet-to-dry dressings

Wet dressings can lead to hypothermia in burn patients, which worsens outcomes. Dry coverings are preferred.

D. Cover with a clean dry sheet to prevent hypothermia

Burn patients lose heat rapidly due to loss of skin integrity. Covering with a clean, dry sheet helps prevent hypothermia and infection before transfer.

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Correct Answer is C

Explanation

A. Review dietary approaches to stop hypertension (DASH) choices in a client with primary HTN
Dietary education requires nursing judgment and assessment, which are outside the CNA’s scope of practice. This should be done by the RN or a dietitian.

B. With one other CNA, logroll a client who has had a bicycle accident
Logrolling is required in patients with spinal precautions, and an RN or physical therapist should oversee or perform the procedure to ensure proper spinal alignment.

C. Obtain a weight on a newly admitted client with diabetes
Measuring weight is within a CNA’s scope of practice, and it does not require clinical judgment. The CNA can obtain the weight and report findings to the RN.

D. Assist a client to the bathroom 1 hour after a lumbar puncture
A client who has undergone a lumbar puncture is at risk for post-procedure headaches and hypotension due to cerebrospinal fluid loss. The RN should assess the client first before allowing ambulation.

A. Reassure the client that information they share with the nurse is confidential B. Instruct that complementary therapies are rarely helpful C. Assess physical appearance and gait D. Review current medication list including dosage & frequency E. Ask about current alcohol or drug use

Correct Answer is ["A","C","D","E"]

Explanation

A. Reassure the client that information they share with the nurse is confidential
Establishing trust and confidentiality is essential in a health interview, especially for clients with neurological deficits who may feel vulnerable.

B. Instruct that complementary therapies are rarely helpful
This statement is not evidence-based and may dismiss patient preferences. Some complementary therapies, such as physical therapy or mindfulness, can be helpful in neurological conditions.

C. Assess physical appearance and gait
Observing physical appearance and gait provides important clues about neurological deficits, such as weakness, ataxia, or tremors.

D. Review current medication list including dosage & frequency
Medication history is critical in neurological assessments, as certain medications (e.g., anticoagulants, anticonvulsants) can impact the client’s condition.

E. Ask about current alcohol or drug use
Alcohol and drug use can contribute to neurological impairment and should be assessed during the history-taking process.

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The nurse is caring for a client with 40% full thickness burned total body surface area (TBSA) in the Emergency Department. The nurse is awaiting transfer to a regional burn center within 20 minutes. What is the most appropriate initial wound care management while awaiting transfer?

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Naxlex Comprehensive Predictor Exams

Which action is safest for the registered nurse (RN) to delegate to the certified nursing assistant (CNA)?

Correct Answer is C

Explanation

A nurse is performing an initial interview of a client who has a neurologic deficit. Which actions by the nurse are MOST appropriate? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","D","E"]

Explanation

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