The nurse is providing care to a client who sustained burns to 70% of the body 6 hours ago. Which of the following new assessment data requires the nurse to notify the healthcare provider?

Heart rate of 90 bpm.

Blood pressure of 96/50 mm Hg.

Urine output of 2 mL/kg per hour

Pain rating of 7 on a 1 to 10 point scale.

Answer and Explanation

The Correct Answer is B

A. Heart rate of 90 bpm: While an elevated heart rate may be expected in response to burn injury and the body's stress response, a heart rate of 90 bpm alone may not be concerning without additional context.

B. Blood pressure of 96/50 mm Hg: This blood pressure reading indicates hypotension, which can be a sign of inadequate tissue perfusion, fluid loss, or shock. It requires prompt notification of the healthcare provider for further assessment and intervention.

C. Urine output of 2 mL/kg per hour: Adequate urine output is important for renal function and fluid balance, and a urine output of 2 mL/kg per hour is within the normal range. While changes in urine output should be monitored, this finding alone does not require immediate notification of the healthcare provider.

D. Pain rating of 7 on a 1 to 10 point scale: Pain management is important in burn care, but a pain rating of 7 on a 1 to 10 scale is not unusual in clients with burns and may not require immediate notification of the healthcare provider unless accompanied by other concerning symptoms.

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Correct Answer is D

Explanation

A. "After the surgery, I will have to be careful with heavy lifting for a few weeks": This statement demonstrates understanding of postoperative precautions, as heavy lifting can strain the surgical site and delay healing.

B. "I know that after the surgery, I will only have one testicle left": This statement indicates awareness of the surgical procedure and its potential outcomes, which is accurate.

C. "I will have to take antibiotics as prescribed by my doctor to prevent infection": This statement reflects understanding of the importance of antibiotic therapy to prevent postoperative infection, which is correct.

D. "I will need to avoid showering for a month after the surgery": This statement is incorrect.

Avoiding showering for a month after surgery is unnecessary and could lead to poor hygiene and potential complications such as infection. The client should be educated that showering is typically allowed after surgery, but they should avoid soaking the incision site in water until it has healed properly.

A. Sterilize dishes before using. B. Maintain good hygiene. C. Cook meats and fish well. D. Avoid consuming raw foods. E. Wash hands frequently

Correct Answer is ["B","C","D","E"]

Explanation

A. Sterilize dishes before using: This is not typically necessary. Washing dishes with hot water and soap or using a dishwasher is sufficient to ensure they are clean.

B. Maintain good hygiene: Good hygiene practices are crucial for immunocompromised individuals to prevent infections.

C. Cook meats and fish well: Properly cooking meats and fish helps to kill any harmful bacteria and parasites that could cause infections.

D. Avoid consuming raw foods: Raw foods, especially meats, eggs, and some vegetables, can harbor harmful bacteria and parasites, posing a risk of infection.

E. Wash hands frequently: Frequent handwashing is one of the most effective ways to prevent the spread of infections.

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The nurse is providing care to a client who sustained burns to 70% of the body 6 hours ago. Which of the following new assessment data requires the nurse to notify the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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