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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A. Consumes spicy snacks daily: Consuming spicy snacks daily is not a known risk factor for laryngeal cancer. Risk factors for laryngeal cancer typically include tobacco use, alcohol consumption, exposure to certain chemicals, and occupational hazards.
B. Uses flavored chewing tobacco: Chewing tobacco, especially flavored varieties, is a known risk factor for laryngeal cancer. Tobacco contains carcinogenic substances that can damage the cells of the larynx, increasing the risk of cancer development.
C. Employed as x-ray technician: Being employed as an x-ray technician is not a known risk factor for laryngeal cancer. However, prolonged exposure to radiation may increase the risk of other types of cancer, such as lung cancer.
D. Partner smokes cigarettes: Secondhand smoke exposure from a partner who smokes cigarettes is a risk factor for laryngeal cancer. Inhaling tobacco smoke, even indirectly, can expose the individual to carcinogens that may contribute to the development of cancer.
E. Employed as industrial painter: Occupational exposure to certain chemicals, such as those found in paint and industrial solvents, is a known risk factor for laryngeal cancer. Industrial painters may be exposed to carcinogens through inhalation or skin contact, increasing their risk of developing cancer.
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.
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