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
... [Show More] 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 clients.
b. Change gloves between wound care on different parts of the clients 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 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
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. 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....... [Show Less]