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 .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A rationale
Pancreatitis can lead to gastrointestinal bleeding. Inflammation of the pancreas can cause damage to the organ’s blood vessels, leading to bleeding. This can be a serious complication of pancreatitis.
Choice B rationale
Peptic ulcer disease is a common cause of gastrointestinal bleeding. Ulcers are sores that develop on the lining of the stomach, upper small intestine, or esophagus. When these ulcers erode into blood vessels, bleeding can occur.
Choice C rationale
Inflammatory bowel disease (IBD), which includes conditions like Crohn’s disease and ulcerative colitis, can cause ulcers in the digestive tract. These ulcers can bleed, leading to gastrointestinal bleeding.
Choice D rationale
Gastrointestinal malignancy, or cancer, can cause gastrointestinal bleeding. Tumors can erode into blood vessels or cause ulcers that bleed.
Choice E rationale
Diverticulosis involves the formation of small pouches in the wall of the digestive tract. These pouches can bleed, leading to gastrointestinal bleeding.
Choice F rationale
Gallbladder disease typically does not cause gastrointestinal bleeding. The gallbladder stores bile, a fluid produced by the liver to digest fats. While gallstones and inflammation of the gallbladder are common, they do not usually lead to gastrointestinal bleeding.
Choice G rationale
Hypothyroidism, a condition in which the thyroid gland does not produce enough thyroid hormone, is not typically associated with gastrointestinal bleeding. Symptoms of hypothyroidism can include fatigue, weight gain, and depression, but not gastrointestinal bleeding.
Correct Answer is B
Explanation
Choice A rationale
A patient with acute pancreatitis sitting in a high Fowler’s position leaning over the bedside table may be experiencing discomfort, but it is not an immediate life-threatening situation.
Choice B rationale
A patient who had bariatric surgery and is reporting shoulder pain and heart racing could be experiencing complications such as a pulmonary embolism, which is a life-threatening condition. This patient should be seen first.
Choice C rationale
A patient who is one-day post-op after an intestinal resection and colostomy and has no effluent in the bag may need further assessment, but it is not an immediate life-threatening situation.
Choice D rationale
A patient with cirrhosis reporting loose stools may be uncomfortable, but it is not an immediate life-threatening situation.
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