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 B
Explanation
A. Drying the sclera with a cotton swab prior to administering eye drops is not recommended and could introduce fibers or cause irritation. Proper eye drop administration does not require drying the sclera.
B. Administering the medications 5 minutes apart is correct because it allows each medication to be absorbed properly, preventing the second drop from washing out the first. This timing helps ensure that both medications are effective.
C. Touching the tip of the dropper to the sclera is incorrect and can introduce contaminants, leading to infection. Eye drops should be administered without the dropper touching the eye to maintain sterility.
D. Holding pressure on the conjunctival sac for 2 minutes is excessive. The recommended practice is to gently press on the nasolacrimal duct for 1-2 minutes after administration to prevent systemic absorption, especially with medications like timolol.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"E"}
Explanation
Pneumonia: The client is at risk for pneumonia due to decreased lung expansion and increased risk of aspiration, especially after abdominal surgery.
Deep vein thrombosis (DVT): The client is at risk for DVT due to prolonged immobility and the increased risk of blood clots associated with surgery.
Urinary retention: The Foley catheter may interfere with the client's ability to void normally, increasing the risk of urinary retention.
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