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 B
Explanation
A. Assist with passive range of motion exercises: While promoting mobility is important for overall well-being, it may not be the priority in a client with Pneumocystis jirovecii pneumonia, which requires respiratory support and oxygenation.
B. Monitor the pulse oximetry every two hours: Monitoring oxygen saturation is crucial in clients with Pneumocystis jirovecii pneumonia to assess respiratory status and the effectiveness of treatment. Hypoxemia is a common complication and requires prompt intervention.
C. Encourage 1 liter of fluid intake in 24 hours: Encouraging adequate fluid intake is important for hydration, but it may not be the priority over monitoring respiratory status in a client with pneumonia.
D. Encourage the client to focus efforts on discharge: Discharge planning is important but should not take precedence over immediate nursing care priorities such as respiratory assessment and monitoring.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
Pneumocystis pneumonia (PCP) is a common opportunistic infection in individuals with AIDS, particularly when their CD4 T-cell count falls below 200/mm3. PCP is caused by the fungus Pneumocystis jirovecii and is a significant cause of morbidity and mortality in AIDS patients. The CD4 T-cell count is a key indicator of immune function in HIV/AIDS patients. A CD4 T-cell count below 200/mm3 is indicative of severe immune suppression and significantly increases the risk of opportunistic infections such as pneumocystis pneumonia.
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