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 A
Explanation
A. The client has a history of bronchial asthma: Propranolol is a non-selective beta-blocker and can potentially exacerbate bronchospasm in individuals with asthma due to its beta-blocking effects on beta-2 receptors in the bronchioles. Therefore, this finding should be reported to the provider for further assessment and consideration of alternative medications.
B. The client has a history of migraine headaches: Propranolol is commonly used prophylactically to prevent migraine headaches, so this finding is not a contraindication for its use and does not require immediate reporting to the provider.
C. The client has a history of hypertension: Propranolol is often prescribed for hypertension, so this finding is expected and not a cause for concern.
D. The client has a history of hypothyroidism: While propranolol can affect thyroid function tests, a history of hypothyroidism alone is not a contraindication for its use, and it does not
require immediate reporting to the provider. However, thyroid function should be monitored during therapy.
Correct Answer is D
Explanation
A. Inform the health care provider that there is a probable leak in the drainage system: Bubbling in the water seal chamber of a chest drainage system during client breathing is an expected finding and indicates air movement in and out of the pleural space. It does not necessarily indicate a leak in the drainage system. Documenting the observation and assessing the client for other signs of complications would be appropriate before informing the healthcare provider.
B. Encourage the client to breathe deeply so the water seal will stabilize: Deep breathing by the client will not stabilize the water seal. The bubbling occurs due to air movement in and out of the pleural space during respiration and is a normal finding.
C. Inform the health care provider that the client is ready to have the chest tube removed: Bubbling in the water seal chamber does not necessarily indicate that the client is ready to have the chest tube removed. The decision to remove a chest tube is based on various factors, including the client's clinical status and resolution of the underlying condition requiring chest drainage.
D. Document that the chest drainage system is functioning as intended: Bubbling in the water seal chamber during client breathing indicates that the chest drainage system is functioning as intended. It is an expected finding and does not typically require intervention.
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