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

Explanation

A. Irregular pulsations: Premature ventricular contractions (PVCs) are abnormal heartbeats originating in the ventricles, causing irregularities in the heart rhythm. Auscultating the apical pulse during PVCs may reveal irregular pulsations due to the irregular timing of ventricular contractions.

B. Bounding pulsations: Bounding pulsations are typically associated with conditions such as hypertension or aortic valve regurgitation but are not specifically characteristic of PVCs.

C. Tachycardia: PVCs may occur in the setting of tachycardia, but the presence of PVCs themselves does not necessarily indicate a rapid heart rate. The rhythm may be irregular due to PVCs, but the overall heart rate may not be consistently elevated.

D. Bradycardia: PVCs are not typically associated with bradycardia. Bradycardia refers to a slow heart rate, while PVCs involve premature extra beats originating from the ventricles.

Correct Answer is "{\"xRanges\":[104.2578125,134.2578125],\"yRanges\":[114.30078125,144.30078125]}"

Explanation

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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

Correct Answer is A

Explanation

Correct Answer is "{\"xRanges\":[104.2578125,134.2578125],\"yRanges\":[114.30078125,144.30078125]}"

Explanation

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