A patient is brought into the emergency department with burns sustained during a house fire. Which of the following should the nurse do first regarding this patient's wounds?
1. cover the wounds with dry gauze
2. wash the wounds with water
3. wash the wounds with hydrogen peroxide
4. ensure that the burning has stopped by removing clothing or other materials from the skin
4
Rationale: The first step in caring for the burn wound is to ensure the burning process has stopped. Clothing, jewelry, belts, or anything containing heat is removed from the patient. If time permits, the wound is gently cleansed with sterile saline or a mild soap and not washed with water or hydrogen peroxide. The wounds should be cleaned before covering with a clean sheet and not dry gauze.
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A physician documents that a patient has a scleral icterus. How does the nurse describe the color of the patient's sclera?
a. Red b. Blue c. Green d. Yellow
A terminally ill client is admitted to a hospice facility. The client has an advanced directive indicating that no heroic measures be used to prolong life. What is the most appropriate nursing action when death appears imminent?
A) Sit quietly and stroke the client's hand. B) Notify the client's clergy of the potential for death. C) Call the funeral home to notify of imminent death. D) Move the client to a private room.
When providing care to critically ill patients, whether they are responsive or unresponsive, the nurse should:
1. Clearly explain what care is to be done before starting the activity. 2. Perform the activity and then let the patient rest without explaining the care. 3. Make sure the patient always responds and is cooperative before giving care. 4. Explain to the family that the patient will not understand or remember any of the discomfort associated with care.
Normal rectal temp
What will be an ideal response?