A.N. does not exhibit any signs of smoke inhalation injury and is admitted to the medical unit for further
treatment.
As her nurse, you are concerned about meeting her needs for infection prevention, skin integ
rity, nutrition, fluids, and psychologic support.
Because of her significant burn injury, A.N. is at high risk for infection. What measures will
you institute to prevent this?
• Place her in a private room and initiate protective isolation procedures. Use aseptic technique with
sterile gloves during dressing changes. All supplies necessary to care for the patient should remain
in the patient's room. No one with an actual or potential infection should care for or visit the
patient.
• Provide family education about infection precautions.
• Administer antibiotics and antipyretics as prescribed.
• Change bed linens daily and whenever soiled.
• A tetanus toxoid would be given because of the likelihood of anaerobic burn wound
contamination.
You might also like to view...
Which nursing interventions are primary in the care of a client receiving internal sealed radiation? Select all that apply
A) Time, distance, and shielding B) Count wires/threads every shift. C) Maintain ink markings on the skin. D) Administer treatments through the intravenous port. E) Provide rest periods between treatments. F) Encourage family involvement in direct care.
In evaluating the effectiveness of an exercise program in an obese client, the nurse should expect the following outcomes:
A) reduced bone density. B) reduced insulin sensitivity. C) increased joint pain. D) enhanced feelings of well-being.
The nurse teaching a type 2 diabetic client how to manage the disease while on a prescribed diet and taking an oral antidiabetic agent would recognize that the client has an accurate understand-ing of diabetes management when the client states
a. "I can use oral medications as long as my pancreas can still produce insulin." b. "I must decrease my total daily fat intake to less than 45% of my total calories." c. "I must exercise at least 1 hour daily to help bring down my sugar." d. "I'm really happy I can take insulin pills; it's much easier than an injection."
The nurse is assessing a patient with an endotracheal tube on mechanical ventilation. Which assessment finding indicates a partially deflated cuff?
a. Increased exhaled tidal volume b. Spasmodic coughing c. Tense test balloon on the endotracheal tube d. Vocalizations by the patient