A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values?
Decreased prothrombin time
Increased hematocrit
Increased sodium
Potassium deficit
The Correct Answer is B
A. Decreased prothrombin time is not typically associated with the emergent phase of a burn injury. Prothrombin time changes are more related to liver function or coagulation disorders.
B. Increased hematocrit is common in the emergent/resuscitative phase of burn injury due to fluid shifts and loss of plasma volume, leading to hemoconcentration.
C. Increased sodium is not typically seen in the emergent phase; instead, hyponatremia may occur due to fluid shifts and loss of sodium in the burn exudate.
D. Potassium deficit is more likely to occur later in the burn management phases. In the emergent phase, hyperkalemia is more common due to cell destruction and release of intracellular potassium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Using a portable electronic thermometer is incorrect as the device must be dedicated to the client to avoid cross-contamination.
B. Wiping the stethoscope with alcohol after use is insufficient because alcohol-based sanitizers are ineffective against C. difficile spores. The stethoscope should be cleaned with bleach-based disinfectant.
C. Removing the protective gown before leaving the client's room is correct as it prevents the spread of C. difficile spores outside the isolation area.
D. Removing the protective gown before removing gloves is incorrect. Gloves should be removed first to prevent contamination when removing the gown.
Correct Answer is B
Explanation
A. Assessing for upper extremity injuries is important, but it is not the highest priority in an unconscious client who is at risk for airway obstruction.
B. Suctioning saliva from the client's mouth is the highest priority because an unconscious client is at risk for airway obstruction due to the accumulation of saliva or other secretions. Maintaining a clear airway is essential to prevent aspiration and ensure adequate oxygenation.
C. Monitoring electrolyte levels is important in the overall management of a client with cerebral hemorrhage, but it is not the immediate priority compared to securing the airway.
D. Recording intake and output is necessary for fluid balance monitoring but is secondary to the immediate need to maintain a patent airway in an unconscious client.
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