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
Starting an intravenous infusion for antiviral drug administration is premature at this stage. The patient’s COVID-19 test results are not yet available, and antiviral drugs should not be administered without a confirmed positive test.
Choice B rationale
Moving the patient to a private room, keeping the door closed, and initiating droplet precautions is the most important action. Given the patient’s symptoms and the significant other’s COVID-19 status, these measures will help prevent potential spread of the virus.
Choice C rationale
Notifying the charge nurse for assignment to the COVID-19 specified area of the facility is important, but it is not the immediate priority. The first step should be to initiate droplet precautions to minimize the risk of transmission.
Choice D rationale
While it is important to inform the patient about potential exposure, the immediate priority is to prevent the spread of the virus within the healthcare facility.

A. Maintain elevated positioning of the dependent joints on the affected side. B. Verify prescribed laboratory tests include prothrombin time and platelet count. C. Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. D. Administer aspirin to prevent further clot formation and platelet clumping.

Correct Answer is C

Explanation

Choice A rationale
While maintaining elevated positioning of the dependent joints on the affected side can be helpful in certain conditions such as edema or injury, it is not the immediate intervention needed for a client presenting with sudden, severe facial numbness, uneven smile with facial droop to the right side, and a hand grasp strength that is weaker on the right than the left.
Choice B rationale
Verifying prescribed laboratory tests including prothrombin time and platelet count is important in assessing the client’s coagulation status. However, it is not the immediate intervention needed in this situation.
Choice C rationale
The client’s symptoms are suggestive of a stroke. In such cases, immediate medical intervention is crucial. Starting two large-bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an appropriate immediate intervention.
Choice D rationale
Administering aspirin can be beneficial in preventing further clot formation and platelet clumping in clients at risk of a stroke. However, it is not the immediate intervention needed in this situation.

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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

Correct Answer is C

Explanation

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