A nurse is caring for a client who has partial-thickness burns on 50% of his body and is receiving total parenteral nutrition. The nurse should actively monitor the client for which of the following?
Decreased calcium levels.
Increased serum glucose levels.
Absent bowel sounds.
Intermittent abdominal pain.
The Correct Answer is B
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
"The lesions may reoccur in times of stress." This statement indicates that the client understands that the virus can reactivate and cause new outbreaks during times of stress.
Choice A is not correct because thevirus can spread to other areas through skin-to-skin contact.
Choice C is not correct because the virus can still be contagious even when no lesions are present.
Choice D is not correct because having unprotected sex can still transmit the virus even while taking acyclovir.
Correct Answer is A
Explanation
The correct answer is: Choice A: Maintain direct pressure over the site.
Here's the rationale for each choice:
- Choice A: Maintain direct pressure over the site (CORRECT) This is the most important initial step in controlling bleeding for any patient, especially one with hemophilia who has a deficiency in clotting factors. Maintaining pressure directly on the wound helps to form a clot and stop the bleeding.
- Choice B: Check whether the bleeding has stopped While checking for bleeding cessation is important, it shouldn't be the immediate next step after applying a dressing. Maintaining pressure ensures the dressing remains effective. Once pressure is released, you can assess for continued bleeding.
- Choice C: Obtain a radial pulse Assessing the radial pulse is not directly related to managing the bleeding from the laceration. While it's a vital sign, it's not a priority in this situation.
- Choice D: Reinforce the dressing over the site While reinforcing the dressing might be necessary later if it becomes saturated with blood, maintaining direct pressure is the crucial first step.
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