Chapter 26
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 clients wounds for signs of infection.
c. Encourage the client to breathe deeply every hour.
d. Wash your hands on entering the clients
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 infection 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 client
b. Change gloves between wound care on different parts of the
clients bo
c. Use the closed method of burn wound management for all
wound care
d. Advocate for proper and consistent handwashing by all
members of th ANS: B
Autocontamination is the transfer of microorganisms from one area
to another area of the same clients body, causing infection of
a previously uninfected area. Although all techniques listed
can help reduce the risk for infection, only changing gloves
between performing wound care on different parts of the
clients body can prevent autocontamination.
DIF: Applying/Application REF: 485
KEY: Infection control| Standard Precautions
Downloaded by Purity Kimani
()
,MSC: Integrated Process: Nursing Process: Implementation
Downloaded by Purity Kimani
()
,NOT: Client Needs Category: Safe and Effective Care
Environment: Safety and Infection Control
3. The nurse teaches burn prevention to a community group.
Which 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 person 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 danger 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
4. A nurse cares for a client who has facial burns. The
client asks, Will I ever look the same? How should the
nurse respond?
a. With reconstructive surgery, you can look the same.
b. We can remove the scars with the use of a pressure dressing.
c. You will not look exactly the same but cosmetic surgery will
help.
d. You shouldnt start worrying about your appearance
right now. ANS: C
Many clients have unrealistic expectations of reconstructive surgery
and envision an appearance identical or equal in quality to
the preburn state. The nurse should provide accurate
information that includes something to hope for. Pressure
dressings prevent further scarring; they cannot remove scars.
Downloaded by Purity Kimani
()
, The client and the family should be taught the expected
cosmetic outcomes.
Downloaded by Purity Kimani
()
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 clients wounds for signs of infection.
c. Encourage the client to breathe deeply every hour.
d. Wash your hands on entering the clients
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 infection 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 client
b. Change gloves between wound care on different parts of the
clients bo
c. Use the closed method of burn wound management for all
wound care
d. Advocate for proper and consistent handwashing by all
members of th ANS: B
Autocontamination is the transfer of microorganisms from one area
to another area of the same clients body, causing infection of
a previously uninfected area. Although all techniques listed
can help reduce the risk for infection, only changing gloves
between performing wound care on different parts of the
clients body can prevent autocontamination.
DIF: Applying/Application REF: 485
KEY: Infection control| Standard Precautions
Downloaded by Purity Kimani
()
,MSC: Integrated Process: Nursing Process: Implementation
Downloaded by Purity Kimani
()
,NOT: Client Needs Category: Safe and Effective Care
Environment: Safety and Infection Control
3. The nurse teaches burn prevention to a community group.
Which 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 person 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 danger 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
4. A nurse cares for a client who has facial burns. The
client asks, Will I ever look the same? How should the
nurse respond?
a. With reconstructive surgery, you can look the same.
b. We can remove the scars with the use of a pressure dressing.
c. You will not look exactly the same but cosmetic surgery will
help.
d. You shouldnt start worrying about your appearance
right now. ANS: C
Many clients have unrealistic expectations of reconstructive surgery
and envision an appearance identical or equal in quality to
the preburn state. The nurse should provide accurate
information that includes something to hope for. Pressure
dressings prevent further scarring; they cannot remove scars.
Downloaded by Purity Kimani
()
, The client and the family should be taught the expected
cosmetic outcomes.
Downloaded by Purity Kimani
()
