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University of Phoenix - NURSING NUR/590BMedical surgical nursing 7th

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Chapter 28: Care of Patients with Burns Test Bank MULTIPLE CHOICE 1. The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most important for the RN to provide t... he LPN? a. Administer the prescribed tetanus toxoid vaccine. b. Assess wounds for signs of infection. c. Have the client cough and breathe deeply. d. Wash 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: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Implementation) 2. When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by autocontamination? a. Avoid sharing equipment such as blood pressure cuffs between 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. Use 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 carrying out wound care on different parts of the client’s body can prevent autocontamination. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Standard Precautions/Transmission-Based Precautions/Surgical Asepsis) MSC: Integrated Process: Nursing Process (Implementation) 3. The nurse is teaching burn prevention to a community group. Which information shared by a member of the group causes the nurse the greatest concern? a. “I get my chimneys swept every other year.” b. “My hot water heater is set at about 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. But the most immediate concern is the person’s smoking upon waking up at night. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Lifestyle Choices) MSC: Integrated Process: Teaching/Learning 4. The nurse is conducting a home safety class. It is most important for the nurse to include which information in the teaching plan? a. Have an escape route everyone knows about. Chapter 1: Introduction to Medical-Surgical Nursing Test Bank MULTIPLE CHOICE 1. Which action demonstrates that the nurse understands the purpose of the Rapid Response Team? a. Monitoring the client for changes in postoperative status such as wound infection b. Documenting all changes observed in the client and maintaining a postoperative flow sheet c. Notifying the physician of the client’s change in blood pressure from 140 to 88 mm Hg systolic d. Notifying the physician of the client’s increase in restlessness after medication change ANS: C The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to clients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code Team, which responds to client arrests, it intervenes rapidly for those who are beginning to decline clinically. It would be appropriate for the RRT to intervene when the client has experienced a 52- point drop in blood pressure. Monitoring the client’s postoperative status, maintaining a postoperative flow sheet, and notifying the physician of a change in the client’s status after a medication change would not be considered activities of the Rapid Response Team. DIF: Cognitive Level: Comprehension/Understanding REF: pp. 2-3 TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with Interdisciplinary Team) MSC: Integrated Process: Nursing Process (Assessment) 2. The Joint Commission focuses on safety in health care. Which action by the nurse reflects The Joint Commission’s main objective? a. Performing range-of-motion exercises on the client three times each day b. Ensuring that the client is eating 100% of the meals served to him or her [Show More]

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