While the client's full-thickness burn wounds to the face and body are exposed, what is the best nursing action to prevent cross-contamination?

Wear gowns, caps, masks, and gloves during care of the client

Turn the room temperature up to at least 70°F (20°C) during dressing changes

Use sterile gloves when removing old dressings

Administer IV antibiotics to prevent bacterial colonization of wounds

Answer and Explanation

The Correct Answer is A

Choice A reason: Full-thickness burns disrupt the skin barrier, increasing infection risk. Wearing gowns, caps, masks, and gloves creates a sterile barrier, preventing cross-contamination from healthcare workers or the environment. This adheres to strict infection control protocols, minimizing the introduction of pathogens like Staphylococcus or Pseudomonas to vulnerable burn wounds.

Choice B reason: Increasing room temperature to 70°F (20°C) during dressing changes aims to prevent patient hypothermia, as burns impair thermoregulation. However, this does not directly address cross-contamination. Temperature control is supportive but does not reduce microbial transmission, making it less effective than personal protective equipment for infection prevention.

Choice C reason: Using sterile gloves when removing old dressings reduces contamination during that specific task. However, it is less comprehensive than full personal protective equipment (gowns, caps, masks, gloves), which protects against contamination throughout care. Sterile gloves alone do not cover potential pathogen spread from other sources, like respiratory droplets or clothing.

Choice D reason: IV antibiotics treat or prevent systemic infections but do not directly prevent cross-contamination of exposed wounds. Prophylactic antibiotics may reduce bacterial colonization but are not the primary method for preventing environmental or contact-based contamination, which is better addressed by physical barriers like gowns and gloves.

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

Explanation

A. The arteriovenous fistula site assessment showing warm skin and palpable brachial and radial pulses indicates a functioning fistula, which is expected and does not require immediate follow-up. A functioning AV fistula is critical for effective hemodialysis, and these findings align with normal post-dialysis assessment.

B. Lung sounds noted as clear do not indicate an issue requiring follow-up. Clear lung fields suggest no fluid overload or pulmonary complications, common concerns in hemodialysis patients, making this finding normal and not necessitating further action.

C. The presence of bruit and thrill at the AV fistula site is a normal finding, confirming patency and adequate blood flow for dialysis. This does not require follow-up, as it indicates the fistula is functioning properly.

D. The blood glucose level of 134 mg/dL in a client with type 2 diabetes mellitus requires follow-up. Post-dialysis, patients with diabetes may experience glycemic variability due to insulin clearance changes during hemodialysis. This level, while not critically high, warrants monitoring to prevent hypo- or hyperglycemia, especially given the client's lethargy and vomiting, which could indicate metabolic instability.

E. Weight assessment post-dialysis is critical and requires follow-up. Hemodialysis removes fluid, and weight changes reflect fluid status. The client’s weight of 90 kg pre-dialysis is noted, but post-dialysis weight is not provided. Monitoring weight is essential to assess fluid removal adequacy and prevent complications like hypotension or fluid overload, aligning with Maslow’s physiological needs for homeostasis.

F. Vital signs, including temperature 36.3°C, heart rate 70/min, respiratory rate 16/min, blood pressure 144/72 mm Hg, and oxygen saturation on room air, are within normal limits post-dialysis. These do not indicate an immediate need for follow-up, as they reflect stable cardiovascular and respiratory status.

A. Hypercapnia with respiratory alkalosis B. Pulmonary hypertension C. Severe hypoxemia despite supplemental oxygen D. Pleural effusion

Correct Answer is C

Explanation

Choice A reason: Hypercapnia with respiratory alkalosis is not typical in ARDS. ARDS primarily causes severe hypoxemia due to alveolar damage and impaired gas exchange. Hypercapnia (elevated CO2) may occur in advanced respiratory failure, but respiratory alkalosis is more associated with hyperventilation in early stress responses, not ARDS’s hallmark of refractory hypoxemia.

Choice B reason: Pulmonary hypertension can develop in ARDS due to hypoxic vasoconstriction and vascular remodeling from inflammation, but it is not the primary or most common symptom. ARDS is characterized by diffuse alveolar damage leading to severe hypoxemia, with pulmonary hypertension being a secondary complication rather than the defining clinical feature.

Choice C reason: Severe hypoxemia despite supplemental oxygen is the hallmark of ARDS. It results from alveolar flooding, surfactant loss, and ventilation-perfusion mismatch, impairing oxygen diffusion. Even high-flow oxygen fails to correct low PaO2 due to shunting and non-functional alveoli, making this the most common and critical symptom requiring urgent intervention.

Choice D reason: Pleural effusion is not a primary feature of ARDS. It may occur in conditions like heart failure or infection but is less common in ARDS, which primarily involves alveolar edema and inflammation. The dominant clinical issue in ARDS is severe hypoxemia due to impaired gas exchange, not fluid accumulation in the pleural space.

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While the client's full-thickness burn wounds to the face and body are exposed, what is the best nursing action to prevent cross-contamination?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

This is an extra credit question: A nurse is caring for a client receiving hemodialysis. Exhibits A nurse is for a client who has received hemodialysis. Which of the following assessment findings require follow-up?

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

Explanation

Which of the following is a clinical symptom most commonly associated with Acute Respiratory Distress Syndrome (ARDS)?

Correct Answer is C

Explanation

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

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The critical care nurse recognizes that which of the following conditions may indicate the need for a client to have a tracheostomy?

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

During change-of-shift report on a medical unit, a client admitted with aspiration pneumonia and respiratory distress has become increasingly agitated. Which action should the nurse take first?

While developing a care plan for a client with full thickness burns, the nurse determines an appropriate goal is to maintain alignment of joints. The goal is to prevent which of the following complications associated with full thickness burns?

A client with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 88%. The client is increasingly lethargic. Which intervention will the nurse anticipate?