While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?
Platelet count.
Serum albumin.
Neutrophil count.
Blood pH level.
The Correct Answer is C
Choice A reason: Platelet count is not directly related to wound infection. Platelets are involved in blood clotting and hemostasis. A low platelet count can increase the risk of bleeding, while a high platelet count can indicate inflammation or malignancy.
Choice B reason: Serum albumin is a measure of protein status and nutritional status. A low serum albumin can indicate malnutrition, liver disease, kidney disease, or fluid imbalance. A high serum albumin can indicate dehydration or chronic infection. Serum albumin is not a specific indicator of wound infection.
Choice C reason: Neutrophil count is a measure of the body's immune response to infection. Neutrophils are the most abundant type of white blood cells and are the first line of defense against bacterial infections. A high neutrophil count can indicate an acute infection, while a low neutrophil count can indicate a weakened immune system or a chronic infection. Neutrophil count is the most relevant laboratory value to evaluate wound infection.
Choice D reason: Blood pH level is a measure of the body's acid-base balance. A normal blood pH level is between 7.35 and 7.45. A low blood pH level can indicate acidosis, while a high blood pH level can indicate alkalosis. Blood pH level can be affected by many factors, such as respiratory function, metabolic function, renal function, and medication use. Blood pH level is not a specific indicator of wound infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Platelet count is not directly related to wound infection. Platelets are involved in blood clotting and hemostasis. A low platelet count can increase the risk of bleeding, while a high platelet count can indicate inflammation or malignancy.
Choice B reason: Serum albumin is a measure of protein status and nutritional status. A low serum albumin can indicate malnutrition, liver disease, kidney disease, or fluid imbalance. A high serum albumin can indicate dehydration or chronic infection. Serum albumin is not a specific indicator of wound infection.
Choice C reason: Neutrophil count is a measure of the body's immune response to infection. Neutrophils are the most abundant type of white blood cells and are the first line of defense against bacterial infections. A high neutrophil count can indicate an acute infection, while a low neutrophil count can indicate a weakened immune system or a chronic infection. Neutrophil count is the most relevant laboratory value to evaluate wound infection.
Choice D reason: Blood pH level is a measure of the body's acid-base balance. A normal blood pH level is between 7.35 and 7.45. A low blood pH level can indicate acidosis, while a high blood pH level can indicate alkalosis. Blood pH level can be affected by many factors, such as respiratory function, metabolic function, renal function, and medication use. Blood pH level is not a specific indicator of wound infection.
Correct Answer is C
Explanation
Choice A reason: Explaining the specific reason for urgent notification is important, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.
Choice B reason: Obtaining a PRN prescription for acetaminophen for fever over 101° F (38.3° C) is a possible recommendation that the nurse can make, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.
Choice C reason: Prefacing the report by stating the client’s name and admitting diagnosis is the first information that the nurse should provide, according to the SBAR communication process. This helps to establish the identity and context of the client and the situation.
Choice D reason: Communicating the pre-transfusion temperatures is part of the assessment that the nurse should provide, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.
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