The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require an intervention by the charge nurse?
a. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound.
b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C).
c. The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change.
d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic patient's serum glucose is elevated.
ANS: A
Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration, and should be used just before and during dressing changes for pain management.
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