What is the first intervention of the nurse for changing the dressing to a painful burn?
Loosen the tape gently by pressing the skin away from it.
Observe the wound bed for presence of granulation tissue.
Administer pain medication 30 minutes beforehand.
Gently irrigate the wound using sterile normal saline.
The Correct Answer is C
Choice A rationale:
Loosening the tape gently by pressing the skin away from it is an important step in changing a burn dressing. However, it is not the first intervention that should be performed. This is because removing the tape can be painful, and it is important to ensure that the patient is adequately pain-free before proceeding.
Choice B rationale:
Observing the wound bed for the presence of granulation tissue is also an important part of burn care. Granulation tissue is a sign of healing, and its presence indicates that the wound is progressing as expected. However, this assessment is not the first priority when changing a dressing. Pain management should always be addressed first.
Choice D rationale:
Gently irrigating the wound using sterile normal saline is another important step in burn care. Irrigation helps to cleanse the wound and remove any debris or dead tissue. However, it should not be performed until the patient's pain has been adequately controlled.
Choice C rationale:
Administering pain medication 30 minutes beforehand is the most important first intervention when changing a painful burn dressing. This allows time for the medication to take effect and ensure that the patient is comfortable before the dressing change begins. Pain management is crucial in burn care, as it can help to reduce anxiety, promote healing, and improve patient outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A superficial abrasion heals by secondary intention, not primary intention.
In secondary intention healing, the wound is left open to heal from the inside out. This type of healing is typically slower and results in more scar tissue formation.
The absence of active bleeding, drainage, or debris is a positive sign, but it does not guarantee that the wound is healing by primary intention.
Choice C rationale:
The presence of thick yellow slough indicates that the wound is infected and not healing properly. This is a sign of delayed healing, not primary intention healing.
Choice D rationale:
The presence of granulation tissue is a sign of healing, but it does not indicate whether the wound is healing by primary or secondary intention.
Granulation tissue is a type of new tissue that forms during the healing process. It is composed of blood vessels, collagen, and fibroblasts.
Correct Answer is C
Explanation
Choice A rationale:
Inaccurate statement: While herbal supplements are derived from plant materials, this does not inherently guarantee their safety or non-toxicity. Some plants contain potent compounds that can have adverse effects, even in small doses.
Lack of regulation: Herbal supplements are not regulated by the FDA in the same way as prescription medications. This means that there is no guarantee of their purity, potency, or consistency.
Potential for interactions: Herbal supplements can interact with prescription medications, potentially leading to harmful side effects.
Choice B rationale:
Cost-related issue: The cost of herbal supplements can vary widely. While some may be less expensive than prescription medications, others can be quite costly.
Misleading focus: Emphasizing cost as a primary factor could lead patients to prioritize affordability over safety and effectiveness.
Choice C rationale:
Addresses quality concerns: This response directly addresses the lack of stringent quality standards for herbal supplements, highlighting a significant safety concern.
Encourages informed decision-making: This response encourages patients to carefully consider the potential risks and benefits of herbal supplements, prompting them to seek reliable information and discuss their choices with healthcare providers.
Choice D rationale:
Convenience vs. safety: While the convenience of herbal supplements may be appealing, this response does not address the potential safety concerns associated with their use.
Potential for misuse: Highlighting convenience could lead to patients using herbal supplements inappropriately or without necessary guidance from healthcare professionals.
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