When caring for a patient with burns, which assessment data will alert the nurse to the possibility of a local infection of the burned area?

Reports pain at burn site

Hands are edematous

Burned area has a foul odor

Temperature is 99.8 degrees Fahrenheit .

Answer and Explanation

The Correct Answer is C

Choice A rationale
While pain at the burn site can be a symptom of many conditions, it is not a specific indicator of a local infection in the burned area.
Choice B rationale
Edematous hands can be a sign of many conditions, including burns, but they are not a specific indicator of a local infection in the burned area.
Choice C rationale
A foul odor from the burned area is a strong indicator of a local infection. Bacteria and other microorganisms that cause infections can produce waste products that have a foul smell.
Choice D rationale
A temperature of 99.8 degrees Fahrenheit is within the normal body temperature range and is not a specific indicator of a local infection in the burned area.

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Correct Answer is ["167"]

Explanation

To calculate the rate for the infusion pump, you would divide the total volume by the total time, then multiply by the drop factor. Here’s how you can do it: Step 1 is: Calculate the total volume in mL, which is 1000 mL.

Step 2 is: Calculate the total time in minutes. Since there are 60 minutes in an hour, 2 hours is 120 minutes.

Step 3 is: Divide the total volume by the total time. So, 1000 mL ÷ 120 min = 8.33 mL/min.

Step 4 is: Multiply the result by the drop factor. If we assume a standard drop factor of 20 drops/mL, then (8.33 mL/min) × 20 drops/mL = 166.67 drops/min. So, the nurse should set the infusion pump to approximately 167 drops per minute. Vital signsVital signs Explore

A. Change the ostomy pouch daily. B. Empty the ostomy pouch when it is 2/3 full. C. Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma. D. Apply lotion to the peristomal skin when changing the ostomy pouch.

Correct Answer is B

Explanation

Choice A rationale
Changing the ostomy pouch daily is not necessary and can lead to skin irritation. The pouch should be changed every 2-4 days or as directed by the healthcare provider.
Choice B rationale
The ostomy pouch should be emptied when it is 1/3 to 1/2 full to prevent leakage and skin irritation.
Choice C rationale
Trimming the opening of the ostomy seal to be 1/2 in. wider than the stoma is incorrect. The opening should be just slightly larger than the stoma to prevent skin irritation.
Choice D rationale
Applying lotion to the peristomal skin when changing the ostomy pouch is not recommended as it can interfere with the adhesion of the pouch.

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When caring for a patient with burns, which assessment data will alert the nurse to the possibility of a local infection of the burned area?

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Naxlex Comprehensive Predictor Exams

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Explanation

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