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.
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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}
Explanation
Intravenous fluid administration is anticipated as hydration can help reduce the viscosity of sickled cells, improving circulation and potentially reducing vaso-occlusive events.
Ice packs to the affected area are nonessential and could potentially be contraindicated, as cold can cause vasoconstriction and may exacerbate pain.
Ambulation is nonessential during acute pain episodes and should be encouraged when the patient is comfortable and pain is controlled.
Hydromorphone IV for pain is anticipated because it is a stronger opioid than morphine and may be necessary if the pain is unresponsive to oral morphine sulfate.
Acetaminophen PO for pain is nonessential in this scenario as it is unlikely to provide adequate pain relief for severe vaso-occlusive pain.
Oxygen therapy is nonessential given the client's SpO2 is 95% on room air, indicating adequate oxygen saturation; however, it may be considered if there is evidence of hypoxia or respiratory distress. It is crucial to monitor the client's response to pain management interventions and adjust the treatment plan accordingly.
Correct Answer is A
Explanation
A. Monitoring for symptoms of anemia is essential as methotrexate can cause bone marrow suppression, leading to anemia. The nurse should instruct the client to report symptoms like fatigue, pallor, and shortness of breath.
B. Methotrexate is more likely to cause gastrointestinal side effects like nausea and loss of appetite rather than an increase in appetite.
C. Methotrexate is typically administered orally or by injection, not via a patch, so rotating the site of patch application is not relevant.
D. Relief of symptoms from methotrexate generally takes several weeks to months. It is important to set realistic expectations about the timeline for symptom improvement.
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