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    Ati Rn Adult Medical Surgical 2023 Proctored Exam

    A nurse is planning care for a client who has full-thickness burns on the lower extremities. Which of the following interventions should the nurse include?

    Explanation & Rationale

    Full-thickness burns destroy both the epidermis and dermis, leaving the underlying tissues highly vulnerable to infection, fluid loss, and delayed healing. Nursing care focuses on strict infection control, pain management, adequate nutrition, and protection of the exposed tissue. Because burn wounds are highly susceptible to contamination, aseptic technique is essential during all dressing and wound care procedures. Preventing cross-contamination between wound sites is a key priority in burn management. A. Cleaning the equipment in the client’s room once per week is not appropriate because burn patients require frequent and strict infection control measures. Equipment used in burn care should be cleaned and disinfected often after each use, to prevent colonization and infection. Weekly cleaning is insufficient for high-risk burn environments. B. Limiting visitation time for the client’s children to 40 minutes per day is not the primary infection control strategy. While visitation may be controlled based on the client’s condition and facility policy, strict time limits alone do not ensure infection prevention. Emphasis is placed more on proper hand hygiene and protective measures rather than arbitrary time restrictions. C. Applying new gloves when alternating between wound care sites is the correct intervention because it prevents cross-contamination between different burn areas. Each wound site is considered a separate potential source of infection, and using fresh sterile gloves for each area maintains aseptic technique. This reduces the risk of transferring microorganisms from one wound to another. D. Providing a diet of fresh fruits and vegetables is not appropriate for a client with severe burns. Burn patients are at high risk for infection, and raw fruits and vegetables may harbor bacteria that could increase infection risk. Instead, a high-protein, high-calorie diet with properly prepared, safe foods is recommended to support wound healing and metabolic demands.

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