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 B

Explanation

Choice A reason: Exposure to persons with pneumonia or chickenpox is not a good idea for anyone, but it is not the main factor that can worsen COPD. COPD is a chronic inflammatory condition that affects the airways and the lungs, and it is mainly caused by smoking or other environmental irritants. Pneumonia and chickenpox are acute infections that can affect the respiratory system, but they are not the primary cause of COPD exacerbation.

Choice B reason: Excessive physical exertion and respiratory tract infections are the most common triggers that can lead to COPD exacerbation, which is a sudden worsening of symptoms, such as shortness of breath, cough, and mucus production. Physical exertion can increase the oxygen demand and the work of breathing, while respiratory infections can cause inflammation and mucus obstruction in the airways. Therefore, the nurse should advise the client to avoid these factors and to seek medical attention if they occur.

Choice C reason: Overdose of albuterol and alcohol consumption are not recommended for anyone, but they are not the main factors that can aggravate COPD. Albuterol is a bronchodilator that can help relax the muscles around the airways and improve breathing, but it can also cause side effects, such as palpitations, tremors, and anxiety, if taken in excess. Alcohol consumption can impair the immune system and the liver function, but it does not directly affect the lungs or the airways.

Choice D reason: Excessive bedrest and lack of exercise are not beneficial for anyone, but they are not the main factors that can exacerbate COPD. Bedrest can lead to muscle weakness and deconditioning, while lack of exercise can reduce the cardiovascular and respiratory fitness. However, these factors do not cause inflammation or obstruction in the airways, which are the main features of COPD. The nurse should encourage the client to maintain a moderate level of physical activity and to follow a pulmonary rehabilitation program if available.

A. Confirmation of the autoimmune disease process. B. Evidence of spread of the disease to the kidneys. C. Indication of the onset of joint degeneration. D. Representative of a decline in the client’s condition.

Correct Answer is A

Explanation

Choice A reason: Rheumatoid factor is an antibody that is produced by the immune system and can bind to normal tissues, causing inflammation and damage. Rheumatoid factor is a marker of the autoimmune disease process that underlies rheumatoid arthritis, which is a chronic condition that affects the joints and other organs. A high level of rheumatoid factor can confirm the diagnosis of rheumatoid arthritis and indicate the severity of the disease.

Choice B reason: Rheumatoid factor is not a specific indicator of kidney involvement in rheumatoid arthritis, which is a rare but possible complication of the disease. Kidney damage can occur due to inflammation of the blood vessels, medication side effects, or dehydration. Kidney function can be assessed by other laboratory tests, such as blood urea nitrogen, creatinine, and urine analysis.

Choice C reason: Rheumatoid factor is not a direct cause of joint degeneration in rheumatoid arthritis, which is a progressive condition that leads to joint deformity and disability. Joint degeneration can occur due to chronic inflammation, erosion of cartilage and bone, and formation of nodules and cysts. Joint damage can be evaluated by physical examination, x-rays, and magnetic resonance imaging.

Choice D reason: Rheumatoid factor is not a reliable predictor of the client’s condition in rheumatoid arthritis, which is a variable and unpredictable disease that can have periods of remission and exacerbation. The client’s condition can be influenced by many factors, such as age, gender, genetics, lifestyle, and treatment. The client’s condition can be monitored by clinical symptoms, functional status, and quality of life.

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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

An adult client, a smoker, has had chronic obstructive pulmonary disease (COPD) for twelve years. When conducting discharge teaching, what should the nurse advise the client to avoid in order to prevent exacerbation of COPD?

Correct Answer is B

Explanation

A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

Correct Answer is A

Explanation

The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing food intake, the nurse should include which type of fluid limitation?

The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?

The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting of low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

A client with metastatic cancer reports a pain level of 10 on a pain scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client’s plan of care?