A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?
A) Instruct the patient to keep the wound site in a dependent position.
B) Administer PRN analgesia as ordered.
C) Assess the patient's peripheral pulses distal to the dressing.
D) Assist with passive range of motion exercises to "set" the new dressing.
Ans: C
Feedback:
Dressings can impede circulation if they are wrapped too tightly. The peripheral pulses must be checked frequently and burned extremities elevated. Dependent positioning does not need to be maintained. PRN analgesics should be administered prior to the dressing change. ROM exercises do not normally follow a dressing change.
You might also like to view...
A client is being admitted to the inpatient psychiatric unit. Which actions would be appropriate for the nurse to assess the client's risk of violence? Standard Text: Select all that apply
1. Wait to assess the client's risk of violence once the psychiatric symptoms have stabilized. 2. Assess history of psychotic illness as this is the most important predictor of violence potential. 3. Ask the client, "What is the most violent thing you have ever done?" 4. Review the client's past records and get information from the client's family. 5. Avoid discussing the client's past history of violence as this could provoke the client.
The nurse reviewing laboratory reports on kidney function identifies a result that suggests decreased renal function, which is:
a. blood urea nitrogen (BUN), 10.5 mg/dL. b. creatinine, 0.6 mg/dL. c. BUN, 15 mg/dL. d. creatinine, 2.0 mg/dL.
The nurse assesses the client who underwent partial removal of the stomach a year ago for the manifestations of
a. anemia. b. high white blood cell count. c. low platelet count. d. shortened bleeding times.
The community health nurse is preparing a teaching plan on motor vehicle accidents. What information will the nurse include in the plan? Select all that apply
a. The risk of being injured or killed in a car crash increases for older adult drivers. b. Young children should be placed in the front seat of a motor vehicle so the driver can watch them. c. Air bags have no effect on injury or death related to motor vehicle accidents. d. Cell phone use while driving is directly correlated with an increase in motor vehicle accidents.