While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?

Platelet count.

Serum albumin.

Neutrophil count.

Blood pH level.

Answer and Explanation

The Correct Answer is C

Choice A reason: Platelet count is not directly related to wound infection. Platelets are involved in blood clotting and hemostasis. A low platelet count can increase the risk of bleeding, while a high platelet count can indicate inflammation or malignancy.

Choice B reason: Serum albumin is a measure of protein status and nutritional status. A low serum albumin can indicate malnutrition, liver disease, kidney disease, or fluid imbalance. A high serum albumin can indicate dehydration or chronic infection. Serum albumin is not a specific indicator of wound infection.

Choice C reason: Neutrophil count is a measure of the body's immune response to infection. Neutrophils are the most abundant type of white blood cells and are the first line of defense against bacterial infections. A high neutrophil count can indicate an acute infection, while a low neutrophil count can indicate a weakened immune system or a chronic infection. Neutrophil count is the most relevant laboratory value to evaluate wound infection.

Choice D reason: Blood pH level is a measure of the body's acid-base balance. A normal blood pH level is between 7.35 and 7.45. A low blood pH level can indicate acidosis, while a high blood pH level can indicate alkalosis. Blood pH level can be affected by many factors, such as respiratory function, metabolic function, renal function, and medication use. Blood pH level is not a specific indicator of wound infection.

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

Explanation

Choice A reason: Teaching the client breathing exercises can help improve lung function, reduce mucus accumulation, and prevent atelectasis and pneumonia. Breathing exercises can include pursed-lip breathing, diaphragmatic breathing, and coughing techniques.

Choice B reason: Establishing a regular bladder routine is not directly related to pulmonary complications. However, it can help prevent urinary tract infections, bladder distension, and incontinence, which are common problems for clients with ALS.

Choice C reason: Performing chest physiotherapy can help mobilize secretions, improve ventilation, and prevent respiratory infections. Chest physiotherapy can include percussion, vibration, and postural drainage.

Choice D reason: Encouraging use of incentive spirometer can help increase lung expansion, improve oxygenation, and prevent alveolar collapse. Incentive spirometer is a device that measures the amount of air the client can inhale and exhale.

Choice E reason: Initiating passive range of motion exercises can help maintain joint mobility, prevent contractures, and improve circulation. Passive range of motion exercises are performed by the nurse or a caregiver who moves the client's limbs through their full range of motion.

A. Use incentive spirometer. B. Monitor urinary stream for decrease in output. C. Report when hematuria becomes pink tinged. D. Restrict physical activities.

Correct Answer is B

Explanation

Choice A reason: Using incentive spirometer is not a relevant instruction for a client with BPH who underwent TUNA. Incentive spirometer is a device that helps improve lung function and prevent respiratory complications after surgery or prolonged bed rest. TUNA is a minimally invasive procedure that uses radiofrequency energy to shrink the prostate tissue and relieve the urinary obstruction. TUNA does not affect the respiratory system or require general anesthesia.

Choice B reason: Monitoring urinary stream for decrease in output is an important instruction for a client with BPH who underwent TUNA. Urinary output can reflect the kidney function and the effectiveness of the procedure. A decrease in urinary output can indicate urinary retention, infection, or bleeding, which are potential complications of TUNA. The client should report any changes in the urinary stream, such as difficulty, pain, frequency, urgency, or hesitancy, to the health care provider.

Choice C reason: Reporting when hematuria becomes pink tinged is not a necessary instruction for a client with BPH who underwent TUNA. Hematuria is the presence of blood in the urine, which is a common and expected finding after TUNA. Hematuria usually resolves within a few days and does not require intervention, unless it is excessive or persistent. The client should drink plenty of fluids to flush out the blood and prevent clot formation. The client should report any signs of infection, such as fever, chills, or foul-smelling urine, to the health care provider.

Choice D reason: Restricting physical activities is a correct instruction for a client with BPH who underwent TUNA. Physical activities can increase the blood pressure and the risk of bleeding or injury to the prostate. The client should avoid strenuous activities, such as lifting, running, or biking, for at least two weeks after the procedure. The client should also avoid sexual intercourse, driving, or sitting for long periods until the symptoms subside. The client should follow the health care provider's advice on when to resume normal activities.

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While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)

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

Explanation

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Correct Answer is B

Explanation

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