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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

Ineffective breathing pattern related to incisional pain and anesthesia is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery because it addresses the most immediate and life-threatening concern: impaired gas exchange.

A. Shearing force. B. Acceleration. C. Momentum. D. Applied force.

Correct Answer is A

Explanation

Choice A rationale:

Shearing force is the primary factor that contributes to the formation of pressure injuries when a patient's body slides downward. It occurs when two surfaces move in opposite directions, causing stress and strain on the tissues between them.

Compression of Tissues: When the patient's body slides downward, the skin and underlying tissues are compressed between the bony prominences (such as the sacrum or heels) and the surface of the bed. This compression restricts blood flow to the area, depriving the tissues of oxygen and nutrients.

Tissue Stretching and Tearing: As the body slides, the skin and underlying tissues are also stretched and pulled in opposite directions. This shearing force disrupts the normal alignment of cells and tissues, leading to microscopic tears and damage.

Impaired Blood Flow: Shearing force further compromises blood flow by stretching and compressing blood vessels. This reduces the delivery of oxygen and nutrients to the tissues, while also hindering the removal of waste products.

Tissue Damage and Necrosis: The combination of compression, stretching, and impaired blood flow leads to cell death and tissue necrosis. This is the hallmark of pressure injuries, which can range from superficial blisters to deep ulcers that extend into muscle and bone.

Factors that Increase Shearing Force: Certain factors can increase the risk of shearing force and pressure injury development, including:

Increased moisture (from sweat or incontinence) Decreased mobility

Poor skin integrity

Malnutrition

Friction from bedsheets

In conclusion, shearing force is the main factor that contributes to pressure injury formation when a patient's body slides downward. It disrupts blood flow, damages tissues, and can lead to significant wounds.

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What is the first intervention of the nurse for changing the dressing to a painful burn?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery?

Correct Answer is A

Explanation

Which factor contributes to the formation of a pressure injury when a patient’s body slides downward to the foot of the bed?

Correct Answer is A

Explanation

Which assessment finding indicates that the patient is at high risk for development of pulmonary embolism?

Four hours after major abdominal surgery, the nurse notes that the patient does not have any bowel sounds. What is the appropriate action for the nurse to take?

Which patient would most likely benefit from a sitz bath?

If a patient has a non-blanchable area of redness on the right malleolus, what stage of pressure injury should be recorded in the patient’s medical record?

A patient develops constipation after taking a daily iron supplement prescribed by the physician. Which term best describes the patient’s reaction to the supplement?

Which medication order is written appropriately?

Which signs would suggest to a nurse that a patient is undergoing a stress response? (Choose all that apply)

A postoperative abdominal surgery patient has been admitted to the surgical floor. The nurse is aware that wound healing is delayed due to complications. Which conditions would prevent normal wound healing at the surgical site? (Select all that apply.)