Nokea
The nurse is caring for a client with several severe pressure ulcers. Which laboratory result requires the nurse to intervene?
- A. Serum albumin level of 2.5 g/dL [3.5-5 g/dL]
- B. Serum potassium level of 4 mEq/L (mmol/L) [3.5 and 5.0 mEq/L (mmol/L)]
- C. Serum sodium level of 140 mEq/L (mmol/L) [135-145 mEq/L (mmol/L)]
- D. White blood cell count of 9,000 cells/uL (9x10%) [4,500-11,000 cells/uL, 3.5-10.5 × 10°/L]
Correct Answer: A
Rationale: A low serum albumin level (2.5 g/dL) indicates malnutrition, which impairs wound healing and requires intervention. Other lab values are within normal ranges.
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The nurse cares for a client who sustained full-thickness thermal burns to 30% of their total body surface area (TBSA). Which of the following initial laboratory values would be expected?
- A. Potassium 5.6 mEq/L (mmol) [3.5-5 mEq/L]
- B. Hematocrit 30% (0.30 L/L) [ Male: 42-52% Female: 37-47%, 0.38-0.50 L/L]
- C. BUN 14 mg/dL (5.0004 mmol/L)[10-20 mg/dL, 2.1-8.0 mmol/L]
- D. Glucose 89 mg/dL (4.94 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]
Correct Answer: A
Rationale: Hyperkalemia (elevated potassium) is expected initially due to cell destruction from burns releasing potassium into the bloodstream.
The emergency department (ED) nurse is caring for a client who sustained a witnessed electrical burn
Item 1 of 1
Triage Note
Triage Vital Signs
1730: A 35-year-old male was brought to the emergency department (ED) by his father after they were working on electrical wiring at a residential house. The client's father witnessed his son grab a wire and sustain a significant 'jolt' for five to ten seconds. The client briefly lost consciousness and was disoriented immediately afterward. The client was immediately placed in the father's car and transported to the ED. A localized burn was noted on the client's right hand. Scant sanguineous drainage noted. The client reports pain of a '6' (0= no pain; 10= severe pain) that is worsened with movement. The client is alert and oriented to place and time; however, he does not recall the situation that brought him to the hospital. Glasgow
Coma Scale (GCS) 14. The client reports that he feels like his 'heart is intermittently skipping.'
The nurse is immediately concerned that the client is at risk for developing …………….. as evidenced by the client's ………………
- A. carbon monoxide poisoning
- B. wound infection
- C. cardiac dysrhythmias
- D. Glasgow Coma Scale
- E. pulse
- F. pain level
Correct Answer: C, E
Rationale: The client's report of feeling like his 'heart is intermittently skipping' indicates a potential cardiac dysrhythmia, which is a serious complication of electrical burns due to the effect of electrical current on the heart. The pulse is the finding that supports this concern.
A nurse is taking care of a client with severe burns. Which of the following is the best intervention to prevent shock in this client?
- A. Administer dopamine as ordered
- B. Apply medical anti-shock trousers
- C. Infuse IV fluids as indicated
- D. Infuse fresh frozen plasma
Correct Answer: C
Rationale: Infusing IV fluids is the best intervention to prevent hypovolemic shock in burn patients by restoring circulating volume lost due to fluid shifts from severe burns.
Which client is at the highest risk for developing a decubitus ulcer among the following patients in a long-term care facility?
- A. An incontinent client who had 3 diarrheal stools
- B. An 80-year-old ambulatory diabetic client
- C. A 79-year-old malnourished client on bed rest
- D. An obese client who occasionally uses a wheelchair
Correct Answer: C
Rationale: The malnourished client on bed rest is at highest risk due to immobility and poor nutritional status, both major contributors to pressure ulcer development.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 6 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
The nurse assesses the urine output and determines whether the client is meeting the treatment goal when it reaches
- A. 0.10 mL/kg/hr
- B. 0.25 mL/kg/hr
- C. 0.4 mL/kg/hr
- D. 0.5 mL/kg/hr
Correct Answer: D
Rationale: A urine output of 0.5 mL/kg/hr indicates adequate renal perfusion and effective fluid resuscitation in burn patients.