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
... [Show More] LPN when assigning this
client?
a. “Administer the prescribed tetanus toxoid vaccine.”
b. “Assess the client’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 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 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 all
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 [Show Less]