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 A

Explanation

Choice A rationale
Auscultating a bruit over the graft area of a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access is a normal finding. A bruit is a vibration felt over the graft that indicates blood flow. Therefore, the nurse should document the findings as it indicates the graft is patent and functioning properly.
Choice B rationale
Elevating the extremity is not necessary in this case. The presence of a bruit indicates that the graft is functioning properly.
Choice C rationale
Applying gentle pressure is not the appropriate intervention in this case. The presence of a bruit is a positive sign indicating the graft is functioning properly.
Choice D rationale
Assessing the client’s temperature is not directly related to the presence of a bruit over the graft area. The temperature would not provide information about the patency or function of the AV graft.

A. Lower back pain and hypotension. B. Delayed painful rash with urticaria. C. Acute rhinitis and nasal stuffiness. D. Arthritic joint changes and chronic pain.

Correct Answer is A

Explanation

Lower back pain and hypotension are symptoms of an ABO incompatibility reaction, which is a serious complication of blood transfusion. This reaction occurs when the client receives a blood type that is incompatible with their own. It can cause a rapid and severe response, including back pain, hypotension, fever, and chills. This should be reported immediately to the healthcare provider.

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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

A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement?

Correct Answer is A

Explanation

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

Correct Answer is A

Explanation

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