a nurse is preparing to change a clients dressing for a burn wound on his foot which of the following interventions is appropriate for this process

NCLEX-RN

Safe and Effective Care Environment NCLEX RN Questions

1. A nurse is preparing to change a client's dressing for a burn wound on his foot. Which of the following interventions is appropriate for this process?

A. Wash the wound with cleanser, rinse, and pat dry
B. Bind the wound tightly, secure with tape, and elevate the foot
C. Contact the physician after the dressing change is complete
D. Provide analgesics for the client after the procedure

Correct answer: A

Rationale: When changing the dressing for a burn wound, it is essential to follow appropriate interventions to prevent infection, reduce pain, and support healing. In this scenario, after removing the old dressing, it is crucial to wash the wound gently with a suitable cleanser, rinse the area thoroughly, and then pat it dry. This process helps in maintaining cleanliness, reducing the risk of infection, and providing a conducive environment for healing. Binding the wound tightly (Choice B) can impede circulation and delay healing. Contacting the physician after the dressing change (Choice C) may be necessary in specific situations but is not a standard step in routine dressing changes. Providing analgesics after the procedure (Choice D) is important for pain management but is not directly related to the dressing change itself.

2. Which of the following is recommended by Joint Commission guidelines regarding the use of restraints?

A. Vest restraints should be used because they are the least restrictive type.
B. Restraints should be used for 48 hours in non-psychiatric patients.
C. Restraints should be applied to prevent wandering behavior.
D. Alternative measures must be attempted first.

Correct answer: D

Rationale: When considering the use of restraints, Joint Commission guidelines emphasize the importance of attempting alternative measures before resorting to restraint application. This ensures that a comprehensive assessment is conducted and less restrictive interventions are explored. Using restraints solely based on their perceived level of restrictiveness, as stated in choice A, is not in line with the recommended approach. Restraints should not be used to manage wandering behavior, as indicated in choice C. Additionally, the statement in choice B regarding the duration of restraint use is inaccurate, as restraints on non-psychiatric patients should not exceed 24 hours according to The Joint Commission.

3. A healthcare professional realizes after a patient has left the office that they forgot to document the patient's complaint of a sore throat. Which of the following choices would BEST correct the error?

A. Pull out that page of the chart and rewrite it with the correct information.
B. Put one line through the original Chief Complaint, write 'ERROR,' your initials, and today's date. Make the correction by rewriting the Chief Complaint with the correct information.
C. Go to the next available line of the SOAP notes. Write the current date, then write 'Late Entry.' Place the date and time when the patient stated they had a sore throat. Sign and date the entry.
D. All of the above are incorrect.

Correct answer: C

Rationale: When adding information to a patient's chart after the encounter, using the term 'Late Entry' is essential. This clearly indicates that the information was added after the fact and helps to maintain the accuracy and integrity of the medical record. Option A is incorrect because removing a page from the chart and rewriting it can lead to inaccuracies and is not a recommended practice for correcting errors. Option B suggests marking the original Chief Complaint as an error, which may not be clear to future readers of the chart and could lead to confusion. Option D is incorrect as it dismisses the correct approach outlined in Option C, which is the best way to handle the situation of missed documentation during a patient encounter.

4. Over a patient's lifespan, how does the pulse rate change?

A. starts out fast and decreases as the patient ages.
B. starts out slower and increases as the patient ages.
C. varies from slow to fast throughout the lifespan.
D. stays consistent from birth to death.

Correct answer: A

Rationale: The correct answer is that the pulse rate starts out fast and decreases as the patient ages. In infants, the normal pulse rate is around 140 beats per minute, which then falls to an average of 80 beats per minute in adults. As individuals age, their pulse rate tends to decrease due to changes in cardiovascular function. Choice B is incorrect as the pulse rate typically decreases with age, rather than increases. Choice C is incorrect as there is a general trend of decreasing pulse rate as individuals age, rather than a continuous variation. Choice D is incorrect as the pulse rate does change over a patient's lifespan, starting fast in infants and decreasing as they age.

5. Which of the following questions is considered open-ended?

A. What time did you last take your medications?
B. Are you feeling okay right now?
C. Please describe your symptoms.
D. What day are you available for a follow-up appointment?

Correct answer: C

Rationale: The correct answer is 'Please describe your symptoms.' This question is considered open-ended because it encourages the respondent to provide a detailed and descriptive answer, fostering a more elaborate response. Open-ended questions are designed to prompt thoughtful and detailed responses. Choice A is a closed-ended question since it seeks a specific time for the medication intake. Choice B is also closed-ended as it can be answered with a simple 'yes' or 'no,' limiting the response. Choice D is closed-ended as it requests a specific day for the follow-up appointment, restricting the range of possible responses.