While caring for a client with a full-thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound.
Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?
Serum blood glucose (BG) level.
Neutrophil count.
Serum albumin.
Hematocrit.
The Correct Answer is B
Choice A rationale:
Serum blood glucose (BG) level is not directly related to the presence of purulent drainage at a burn wound site. Elevated BG levels might be seen in clients with diabetes or as a stress response, but they are not the primary indicator of infection or wound complications.
Choice C rationale:
Serum albumin levels can be relevant in assessing nutritional status and the body's ability to heal wounds. However, they do not directly indicate the presence of infection or purulent drainage. Low serum albumin levels may be seen in clients with malnutrition but do not provide immediate information about the wound.
Choice D 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Notify your healthcare provider if you start having abdominal pain.
Choice A rationale:
Exenatide does not act in the same way as insulin. Insulin directly lowers blood glucose levels by facilitating the uptake of glucose into cells, while exenatide is an incretin mimetic that enhances glucose-dependent insulin secretion and slows gastric emptying.
Choice B rationale:
Exenatide should be injected within 30 minutes before or after a meal, but this is not the most critical information for discharge instructions.
Choice C rationale:
There are precautions about taking exenatide with other medications, especially those that affect kidney function or interact with exenatide.
Choice D rationale:
Notifying the healthcare provider if abdominal pain starts is crucial because exenatide can cause side effects such as pancreatitis, which presents with severe abdominal pain. Early detection and intervention are essential for patient safety.
Correct Answer is D
Explanation
Choice A rationale:
Systemic autoimmune vasculopathy is not a typical underlying disease pathology associated with a waddling gait and frequent falls in a 5-year-old child. This choice is not relevant to the symptoms described.
Choice B rationale:
Autonomic neuropathy may manifest with a variety of symptoms, including autonomic dysregulation, but it is not a common underlying pathology leading to a waddling gait and frequent falls in a child. This choice is not relevant to the symptoms described.
Choice C rationale:
Impaired neuron function can result in various neurological symptoms, but it does not specifically explain the waddling gait and frequent falls in a 5-year-old child. This choice is not relevant to the symptoms described.
Choice D rationale:
Muscle fiber degeneration is the most appropriate explanation for the symptoms of a waddling gait and frequent falls in a 5-year-old child. These symptoms are indicative of a neuromuscular disorder known as Duchenne muscular dystrophy (DMD), which involves progressive muscle weakness and degeneration. DMD is characterized by the loss of muscle fibers and is a common cause of a waddling gait and falls in affected children. Therefore, choice D is the correct answer based on the understanding of the underlying disease pathology.
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