1. When turning an immobile bedridden client without assistance, which action by the nurse
best ensures client safety?
A Securely grasp the client's arm and leg.
.
B. Put bed rails up on the side of bed opposite from
...
1. When turning an immobile bedridden client without assistance, which action by the nurse
best ensures client safety?
A Securely grasp the client's arm and leg.
.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D Lower the head of the client's bed slowly.
.
Rationale:
Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to the skin or joint. Options C and D are useful techniques while turning a client but have less priority in
terms of safety than use of the bed rails.
2. The nurse identifies a potential for infection in a client with partial-thickness (seconddegree) and full-thickness (third-degree) burns. What intervention has the highest priority
in decreasing the client's risk of infection?
A. Administration of plasma expanders
B. Use of careful handwashing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns
Rationale:
Careful handwashing technique is the single most effective intervention for the prevention of
contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn
trauma but is not related to decreasing the proliferation of infective organisms. Options C and D
are recommended by various burn centers as possible ways to reduce the chance of infection.
Option B is a proven technique to prevent infection.
Continued.........
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