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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale
During the fluid resuscitation phase of burn management, the primary goal is to restore circulating volume and preserve vital organ and tissue perfusion. One of the most effective methods for assessing the results of fluid resuscitation is monitoring urine output. A urine output greater than 0.5 mL/kg/hr is generally considered an indicator of adequate fluid resuscitation.
Choice B rationale
While clear bilateral breath sounds are an important part of overall patient assessment, they are not the best method for assessing the results of fluid resuscitation in burn management.
Choice C rationale
Serum hemoglobin is not the best indicator for assessing the results of fluid resuscitation in burn management. While it can provide information about the patient’s overall health and blood volume, it does not directly reflect the adequacy of fluid resuscitation.
Choice D rationale
A heart rate of 122/min could indicate a response to pain, anxiety, or inadequate fluid resuscitation. However, it is not the best method for assessing the results of fluid resuscitation in burn management.

A. Hold tube feeding 1 hour before and 2 hours after to avoid clumping. B. Monitor the patient for lethargy and drowsiness as these may indicate a high drug level. C. Inform the patient that they may experience increased and large amounts of urinary output. D. Advise the patient to use an extra soft toothbrush to avoid gum bleeding.

Correct Answer is B

Explanation

Choice A rationale
Holding tube feeding 1 hour before and 2 hours after to avoid clumping is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice B rationale
Monitoring the patient for lethargy and drowsiness is important as these may indicate a high drug level of Dilantin (phenytoin), which can lead to toxicity.
Choice C rationale
Informing the patient that they may experience increased and large amounts of urinary output is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice D rationale
Advising the patient to use an extra soft toothbrush to avoid gum bleeding is a general recommendation for patients on anticoagulant therapy, not specifically for those taking Dilantin (phenytoin)1011.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client during the fluid resuscitation phase of burn management. Which of the following is the best method for assessing the results of the fluid resuscitation?

Correct Answer is A

Explanation

Which of the following nursing interventions should the nurse utilize when administering Dilantin (phenytoin) in a patient who has a known seizure disorder?

Correct Answer is B

Explanation

A nurse is preparing to administer heparin subcutaneously to a client. Which action by the nurse is appropriate?

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?

The nurse is performing pin care for a patient with an external fixation device for a fractured tibia. Which assessment finding by the nurse should be reported to the unit care coordinator?

A nurse is assessing a client with a major burn injury. Which of the following findings should the nurse prioritize?

A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a patient diagnosed with Hodgkin disease who has significant cervical lymph node enlargement. Which symptom should the nurse address first?

Following an explosion at a local chemical lab, several people have sustained burns and are now in the triage area. Which patient should be attended to first?

A nurse is assisting in the care of a client who has developed cardiogenic shock. Which pulse site should the nurse use when assessing circulation to the client’s brain?