Nokea
The nurse is caring for the client who is diagnosed with a carbuncle. Which home measures should the nurse discuss? Select all that apply.
- A. Leave the draining lesion open to the air so it dries.
- B. Use strict hand washing to prevent cross-contamination.
- C. Cover the mattress and pillows with plastic covers.
- D. Apply ice to the affected area 20 minutes twice daily.
- E. Wash all linens, towels, and clothing after each use.
- F. Remove all throw rugs to prevent tripping or falls.
Correct Answer: B,C,E
Rationale: Treatments for an infected lesion should include strict hand washing to prevent cross-contamination. Covering mattress and pillows with plastic covers and washing all linens, towels, and clothing after each use will prevent cross-contamination. Leaving the lesion open to air is not advised; a dressing is needed. Applying ice or removing throw rugs does not pertain to carbuncle treatment.
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The nurse completes teaching the client with a second-degree burn about silver sulfadiazine. Which client statements should indicate to the nurse that the teaching was effective? Select all that apply.
- A. I apply the cream only to the opened areas of the burned area.
- B. Silver sulfadiazine will prevent an infection of the burned area.
- C. I never should apply a dressing after applying silver sulfadiazine.
- D. I use a tongue blade to remove the old ointment before reapplying.
- E. The cream is dark colored and cannot be removed with water.
Correct Answer: A,B
Rationale: Silver sulfadiazine (Silvadene) is only applied to opened areas; this statement indicates client understanding of the instructions. Silver sulfadiazine is used to reduce/prevent bacterial growth and thus an infection; this statement indicates client understanding of the instructions. Dressings can be applied but are not necessary; this statement does not indicate client understanding. Removal of old ointment with a tongue blade can damage new granulation tissue; this statement does not indicate client understanding. The cream is white in color and water-soluble; if it darkens it should not be used; this statement does not indicate client understanding.
Shortly before each debridement, which nursing intervention is essential?
- A. Keeping the client in a fasting state
- B. Witnessing a signed consent form
- C. Administering a prescribed analgesic
- D. Weighing the client on a bed scale
Correct Answer: C
Rationale: Analgesics are essential to manage pain during debridement.
A severely burned man had his last tetanus shot when he started work at his job two years ago. What should the nurse expect to administer now?
- A. Tetanus toxoid booster
- B. Tetanus antitoxin
- C. Hyperimmune human tetanus globulin
- D. DPT booster
Correct Answer: A
Rationale: A tetanus toxoid booster is appropriate for a burn client with a tetanus shot within the past five years to ensure immunity against tetanus, common in burn wounds.
Which client physiological outcome (goal) is appropriate for a client diagnosed with skin cancer who has had surgery to remove the lesion?
- A. The client will express feelings of fear.
- B. The client will ask questions about the diagnosis.
- C. The client will state a diminished level of pain.
- D. The client will demonstrate care of the operative site.
Correct Answer: D
Rationale: Demonstrating operative site care ensures healing and prevents infection, a physiological outcome. Fear, questions, and pain are psychosocial or secondary.
What is the scientific rationale for placing lift pads under an immobile client?
- A. The pads will absorb any urinary incontinence and contain stool.
- B. The pads will prevent the client from being diaphoretic.
- C. The pads will keep the staff from workplace injuries such as a pulled muscle.
- D. The pads will help prevent friction shearing when repositioning the client.
Correct Answer: D
Rationale: Lift pads reduce friction and shear during repositioning, preventing skin breakdown. Absorbent pads address incontinence, diaphoresis is unrelated, and staff safety is secondary.