A client comes to the emergency department with major burns over 40% of his body. Although all of the following are true, which one would provide the rationale for a nursing diagnosis of Risk for Infection?

Correct Answer: C

Rationale: Step 1: Major burns disrupt the integrity of the skin, the body's first line of defense against infection. Step 2: Intact skin and mucous membranes protect against microbial invasion by acting as physical barriers. Step 3: When these barriers are compromised, such as in major burns, the risk for infection increases. Step 4: Therefore, the rationale for a nursing diagnosis of Risk for Infection in a client with major burns is due to the compromised protection provided by intact skin and mucous membranes.

Correct Answer: C

Rationale: The correct answer is C: Sweat. Standard precautions are recommended for all bodily fluids and substances that may contain bloodborne pathogens. Sweat does not typically contain a significant amount of pathogens compared to blood, urine, and vomitus. Therefore, the CDC guidelines do not designate standard precautions for sweat. Urine (A), blood (B), and vomitus (D) are all bodily fluids that can potentially contain pathogens and require standard precautions to prevent transmission of infections.

Correct Answer: B

Rationale: The correct answer is B: Wear a pair of sterile latex gloves. This is the appropriate intervention to protect the nurse from infection while cleaning open wounds. Sterile latex gloves create a barrier between the nurse's hands and the client's wound, minimizing the risk of cross-contamination. Alcohol-based hand wash (choice A) is important for hand hygiene but does not provide sufficient protection for open wound cleaning. Sterilizing acid (choice C) is too harsh and can damage the wound tissue. Using sterile solutions such as normal saline (choice D) is beneficial for wound irrigation but does not replace the need for gloves to protect against infection transmission.

Correct Answer: A

Rationale: The correct answer is A: 20 seconds. This is in line with the CDC guidelines, which recommend scrubbing hands for at least 20 seconds for effective hand hygiene. This duration allows for adequate removal of germs and pathogens. Choices B, C, and D are incorrect as they exceed the necessary time for hand scrubbing, which can lead to unnecessary skin irritation and wastage of resources. Option B (30 seconds) is slightly longer than needed, while options C (1 minute) and D (5 minutes) far exceed the recommended time, making them impractical and potentially harmful to the skin.

Correct Answer: C

Rationale: The correct answer is C: "What medications are you currently taking?" This is the priority question because it helps the nurse assess if the symptoms could be related to any medications the patient is currently taking. Certain medications can cause vaginal discharge or itching as side effects. A: "When was the last time you visited your primary health care provider?" - While important for overall health history, it is not as critical as determining current medications. B: "Has this condition affected your eating habits in any way?" - While dietary habits can affect overall health, it is not directly relevant to the current symptoms. D: "Are you able to sleep at night?" - While sleep is important, it is not the priority when assessing a patient with vaginal discharge and itching.