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 choiced. Notify your healthcare provider if you start having abdominal pain.
Choice A rationale:
Exenatide does not act in the same way as insulin. It is a GLP-1 receptor agonist that enhances glucose-dependent insulin secretion, suppresses glucagon secretion, and slows gastric emptying.
Choice B rationale:
Exenatide should be injected within 60 minutes before the morning and evening meals, not within 30 minutes before or after a meal.
Choice C rationale:
There are precautions about taking exenatide with other medications. It can affect the absorption of oral medications, so timing and interactions need to be considered.
Choice D rationale:
Abdominal pain can be a sign of pancreatitis, a serious side effect of exenatide.It is important to notify the healthcare provider if this symptom occurs.
Correct Answer is C
Explanation
Choice A rationale:
Referring the client to a social worker for support therapy may be premature at this stage. The client's initial reaction may be due to fear or anxiety about the diagnosis and self-administration of insulin. Pushing the client into therapy without assessing their readiness may not be appropriate.
Choice B rationale:
Encouraging the client to implement relaxation techniques assumes that the client is open to learning and just needs help with anxiety management. However, the client's refusal to have the nurse in the room suggests that they are not currently receptive to teaching. It's important to address the client's emotional state first.
Choice C rationale:
Leaving the client's room and returning later in the day is the most appropriate initial action. The client's loud refusal indicates a need for privacy and emotional space. By respecting the client's wishes and revisiting the teaching later, the nurse can establish trust and build a better rapport.
Choice D rationale:
Explaining that insulin is a life-saving drug is informative but may not be effective in this situation, as the client has already requested the nurse to leave the room. Providing information about the importance of insulin should come after establishing a therapeutic nurse-client relationship.
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