CH 26

Which nursing intervention(s) decrease(s) the risk for cross-contamination in the client with a severe burn injury? Select all that apply. A. Place client in isolation. B. Encourage multiple visitors to support client. C. Ensure that no plants or flowers are in the client's room. D. Teach family members not to bring fresh fruit and vegetables to the client. E. Change gloves after cleaning and dressing of one wound area, before cleaning and dressing another.

A,C,D

The nurse is encouraging range-of-motion exercises for the client, who states, "This hurts terribly; I don't want to do this." Identify the appropriate nursing response(s). Select all that apply. A. "You have to do the exercises to get well." B. "Range of motion helps promote mobility." C. "Just visualize a beach to get your mind off of the pain." D. "Let me check when you were last given pain medication." E. "Which techniques for pain management have you used in the past that were helpful?" F. "The health care provider has ordered these exercises, and it is important that you do them as instructed."

B,D,E

The client asks about ways to prevent carbon monoxide poisoning. Which teaching will the nurse provide? A. "You can see black smoke when carbon monoxide is in the air." B. "If you are experiencing carbon monoxide poisoning, your skin will begin to turn blue." C. "The only way to get poisoned from carbon monoxide gas is if you are in the presence of a fire." D. "It is important to have carbon monoxide detectors in your home because this is an odorless gas."

D

Which assessment finding does the nurse interpret as demonstrating a client's fluid resuscitation adequacy? A. Decreased skin turgor B. Decreased pulse pressure C. Decreased core body temperature D. Decreased urine specific gravity

D