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 A
Explanation
A. Petechiae are small, red or purple spots on the skin that indicate bleeding under the skin and are a classic sign of thrombocytopenia, a condition characterized by a low platelet count.
B. A decreased white blood cell count is more indicative of leukopenia, not thrombocytopenia. Thrombocytopenia specifically affects platelet counts.
C. Increased fatigue can be a symptom of many conditions but is not specific to thrombocytopenia. It may occur due to anemia or other side effects of chemotherapy.
D. Unexplained bone pain is not a typical symptom of thrombocytopenia. It might be related to other conditions or side effects but is not specific to low platelet counts.
Correct Answer is A
Explanation
A. Assessing current anticoagulant use is a priority because t-PA (tissue plasminogen activator) can increase the risk of bleeding, especially if the client has been on anticoagulant medications. It is crucial to determine if there are any contraindications or increased risks for bleeding.
B. While blood pressure control is important, it is secondary to understanding the client's anticoagulant use as it directly affects the safety of t-PA administration.
C. A complete neurologic assessment is important but comes after ensuring there are no contraindications such as recent anticoagulant use that could affect the safety of t-PA.
D. Current treatment for peptic ulcer disease may be relevant for bleeding risks but is not as immediately critical as reviewing anticoagulant use for t-PA safety.
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