Galen College of Nursing - MEDSURG 2 NUR 265 EXAM 3 - TEST BANK (All Correct)
Chapter 26: Care of Patients with Burns
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (L...
galen college of nursing medsurg 2 nur 265 exam 3 test bank all correct
galen college of nursing medsurg 2 nur 265 exam 3 test bank
galen college of nursing medsurg 2 nur 265 exam 3
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Galen College of Nursing - MEDSURG 2 NUR 265 EXAM 3 - TEST BANK (All Correct) Chapter 26: Care of Patients with Burns Ignatavicius: Medical -Surgical Nursing, 8th Edition MULTIPLE CHOICE 1. The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a. “Administer the prescribed tetanus toxoid vaccine.” b. “Assess the c lient’s wounds for signs of infection.” c. “Encourage the client to breathe deeply every hour.” d. “Wash your hands on entering the client’s room.” ANS: D Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing i nfection transmission. DIF: Applying/Application REF: 466 KEY: Infection control| Standard Precautions| collaboration MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a. Use a disposable blood pressure cuff to avoid sharing with other clients. b. Change gloves between wound care on different parts of the client’s body. c. Use the closed method of burn wound management for all wound care. d. Advocate for proper and consistent handwashing by all members of the staff. ANS: B Autocontamination is the transfer of microorganisms from one area to another area of the same client’s body, causing infection of a previously uninfected area. Although a ll techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the client’s body can prevent autocontamination. DIF: Applying/Application REF: 485 KEY: Infection control| Standard Precautions MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. The nurse teaches burn prevention to a community group. W hich statement by a member of the group should cause the nurse the greatest concern? a. “I get my chimney swept every other year.” b. “My hot water heater is set at 120 degrees.” c. “Sometimes I wake up at night and smoke.” d. “I use a space heater when it gets below zero.” ANS: C House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this per son about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much dang er as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140° F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding. DIF: Applying/Application REF: 472 KEY: Safety| smoking cessation MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance
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