A nurse is caring for a client in the emergency department who experienced a full-thickness burn injury to the lower torso 1 hr ago.
Which of the following findings should the nurse expect?
Urinary diuresis.
Hypotension.
Decreased respiratory rate.
Bradycardia.
The Correct Answer is B
A full-thickness burn injury can result in fluid loss and low blood volume (hypovolemia), which can lead to hypotension.
Choice A, Urinary diuresis, is not the correct answer because it refers to increased production of urine and is not a common symptom of a full-thickness burn injury.
Choice C, Decreased respiratory rate, is not the correct answer because it refers to a decrease in the number of breaths per minute and is not a common symptom of a full-thickness burn injury.
Choice D, Bradycardia, is not the correct answer because it refers to a slow heart rate and is not a common symptom of a full-thickness burn injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Acupuncture is commonly used to treat a wide range of illnesses and ailments including pain management, control of nausea and vomiting, fatigue, hot flashes, xerostomia, neuropathy, anxiety, depression, and sleep disturbance in cancer patients.
However, I could not find any information that suggests mouth sores (B), headaches, or urticaria (D) are contraindications for acupuncture.
Lymphedema is a contraindication for acupuncture because it can increase the risk of infection in the affected area.
It is important for the nurse to identify this as a contraindication to receiving acupuncture therapy.
Correct Answer is A
Explanation
“The client’s capillary refill in the left toe is 6 seconds.” Capillary refill time is the time it takes for blood to return to the capillaries after pressure has been applied to the skin.
A normal capillary refill time is less than 2 seconds.
A capillary refill time of 6 seconds indicates poor blood flow to the left toe and requires immediate intervention by the nurse.
Choice B is not the correct answer because while a pain level of 7 on a scale from 0 to 10 at the operative site is concerning, it does not require immediate intervention by the nurse.
Choice C is not the correct answer because an oral temperature of 38.3° C (100.9° F) is only slightly elevated and does not require immediate intervention by the nurse.
Choice D is not the correct answer because while 100 mL of blood in a closed-suction drain may be concerning, it does not necessarily require immediate intervention by the nurse.
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