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.

Answer and Explanation

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.

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Correct Answer is ["A","C","D"]

Explanation

A. Health care providers should be told about the diagnosis to deliver safe care: Health care providers need to know the client's diagnosis to provide appropriate and safe care. This includes administering medications, assessing for opportunistic infections, and implementing preventive measures.

B. Most people in current society would be accepting of the diagnosis: While stigma surrounding HIV/AIDS has decreased over time, disclosure is a personal decision, and not all individuals may be accepting of the diagnosis. Therefore, this statement may not always be accurate.

C. Intimate partners should be told so they can protect themselves: Disclosing the diagnosis to intimate partners is essential for their health and well-being, as it allows them to take necessary precautions to prevent transmission of the virus.

D. The diagnosis is reportable to the state health department: In many jurisdictions, HIV/AIDS diagnoses are reportable to the state health department for surveillance and public health monitoring purposes. This reporting is typically done without disclosing the client's identity.

E. Secrecy about the diagnosis is the privilege of the client: While confidentiality is crucial, it's important to balance it with public health considerations and the well-being of others who may be at risk of infection.

A. Sterilize dishes before using. B. Maintain good hygiene. C. Cook meats and fish well. D. Avoid consuming raw foods. E. Wash hands frequently

Correct Answer is ["B","C","D","E"]

Explanation

A. Sterilize dishes before using: This is not typically necessary. Washing dishes with hot water and soap or using a dishwasher is sufficient to ensure they are clean.

B. Maintain good hygiene: Good hygiene practices are crucial for immunocompromised individuals to prevent infections.

C. Cook meats and fish well: Properly cooking meats and fish helps to kill any harmful bacteria and parasites that could cause infections.

D. Avoid consuming raw foods: Raw foods, especially meats, eggs, and some vegetables, can harbor harmful bacteria and parasites, posing a risk of infection.

E. Wash hands frequently: Frequent handwashing is one of the most effective ways to prevent the spread of infections.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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