A patient with a full-thickness burn covering 40% of their body is exhibiting purulent drainage at the wound site. Before reporting this finding to the healthcare provider, which of the patient’s laboratory values should the nurse review?

Blood pH level

Hematocrit

White blood cell (WBC) count

Platelet count

Answer and Explanation

The Correct Answer is C

Choice A rationale
Blood pH level is a measure of the acidity or alkalinity of the blood. While it’s an important measure in many medical situations, it’s not directly related to the presence of purulent drainage at a burn wound site.
Choice B rationale
Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.
Choice C rationale
The White Blood Cell (WBC) count is a key indicator of infection or inflammation in the body. An elevated WBC count can indicate an infection, which could be the cause of the purulent drainage observed at the burn wound site.
Choice D rationale
Platelet count is a measure of the number of platelets in the blood. Platelets are involved in clotting and wound healing, but they do not directly indicate the presence of an infection that could cause purulent drainage.

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Correct Answer is B

Explanation

Choice A rationale
Decreasing the flow rate of the irrigation solution is not the best action in this situation. The presence of blood clots in the tubing and collection bag indicates that the client may be experiencing clot retention, which can lead to urinary obstruction. Decreasing the flow rate may not provide sufficient force to dislodge clots from the catheter, which could exacerbate the problem.
Choice B rationale
Manually irrigating the catheter is the most appropriate action when blood clots are observed in the tubing and collection bag. Clots can obstruct the catheter and disrupt the continuous bladder irrigation, leading to urinary retention and increased discomfort for the client. Manual irrigation can help dislodge and remove these clots, ensuring the patency of the catheter and the effectiveness of the irrigation.
Choice C rationale
Discontinuing the infusion of the irrigation solution is not the best action in this situation. The purpose of continuous bladder irrigation after a transurethral resection of the prostate is to prevent clot formation and retention by continuously flushing the bladder. Discontinuing the infusion could lead to the formation of more clots, potentially causing urinary obstruction.
Choice D rationale
While monitoring catheter drainage is an important part of postoperative care, it is not the most appropriate action in this situation. The presence of blood clots in the tubing and collection bag indicates a potential problem that requires immediate intervention. Simply monitoring the situation without taking action to resolve it could lead to urinary obstruction and increased discomfort for the client.

A. The patient should adjust their food intake to three full meals per day with no snacks. B. The patient should avoid participating in any aerobic exercise programs. C. The patient should sleep without pillows at night to maintain neck alignment. D. The patient should wear loose, comfortable clothing to minimize symptoms.

Correct Answer is D

Explanation

Choice A rationale
Adjusting food intake to three full meals per day with no snacks is not necessarily recommended for GERD patients. Smaller, more frequent meals can help prevent the stomach from becoming too full and causing reflux.
Choice B rationale
Avoiding participation in any aerobic exercise programs is not a general recommendation for GERD patients. While some exercises may worsen GERD symptoms, many forms of aerobic exercise can be performed without triggering symptoms.
Choice C rationale
Sleeping without pillows at night to maintain neck alignment is not typically recommended for GERD patients. Elevating the head of the bed can actually help prevent acid reflux during sleep.
Choice D rationale
Wearing loose, comfortable clothing can help minimize GERD symptoms. Tight clothing can put pressure on the abdomen and the lower esophageal sphincter, potentially causing reflux.

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A patient with a full-thickness burn covering 40% of their body is exhibiting purulent drainage at the wound site. Before reporting this finding to the healthcare provider, which of the patient’s laboratory values should the nurse review?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

What information should the nurse include in the teaching plan for a patient diagnosed with gastroesophageal reflux disease (GERD)?

Correct Answer is D

Explanation

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