The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most important for the RN to provide the LPN?
A. Administer the prescribed tetanus toxoid vaccine.
B. Assess wounds for signs of infection.
C. Encourage the client to cough and breathe deeply.
D. Wash hands on entering the client's room.
Correct Answer: D. Wash hands on entering the client’s room.
Infection can occur 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.
Option A: 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 B: Examine wounds daily, note and document changes in appearance, odor, or quantity of drainage. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention.
Option C: Although all the interventions listed can help reduce the risk of infection, hand washing is the most effective technique for preventing infection transmission. Airway obstruction and/or respiratory distress can occur very quickly or may be delayed, e.g., up to 48 hr after a burn.
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