Burns and Burn Injury Q 89

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Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds?

  

    A. Handwashing on entering the client’s room

    B. Encouraging the client to cough and deep breathe

    C. Administering the prescribed tetanus toxoid vaccine

    D. Changing gloves between cleansing different burn areas

    

    

Correct Answer: A. Handwashing on entering the client’s room

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Cross-contamination occurs when microorganisms from another person or the environment are transferred to the client. Handwashing with soap and water is the best way to get rid of germs in most situations. Emphasize and model good handwashing techniques for all individuals coming in contact with the patient.

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Option B: Although all the interventions listed above can help reduce the risk of infection, only handwashing can prevent cross-contamination. Airway obstruction and/or respiratory distress can occur very quickly or may be delayed, e.g., up to 48 hr after a burn.

Option C: Tissue destruction and altered defense mechanisms increase the risk of developing tetanus or gas gangrene, especially in deep burns such as those caused by electricity.

Option D: Serious complications often can be avoided by following strict aseptic techniques. Use of a mask, hat, gown, and sterile gloves, and drapes during placement of central venous catheters (CVCs) should be strictly implemented.

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