While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?
Hematocrit.
Blood pH level.
Platelet count.
White blood cell (WBC) count.
The Correct Answer is D
A. While hematocrit levels provide information about blood volume status, they are not directly relevant to infection status or wound healing in burn patients.
B. Blood pH levels can indicate acid-base imbalances, but they do not specifically inform the nurse about the presence of infection.
C. Platelet count is important for assessing coagulation and bleeding risks, but it does not provide direct information regarding infection.
D. White blood cell (WBC) count is critical in assessing for infection, as an elevated WBC count can indicate the presence of an infection, particularly in a client with significant burns who is at increased risk for sepsis.
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Correct Answer is C
Explanation
A. A nursing care plan in the medical record before assessing the patient so that the nurse can identify priorities. The nurse should assess the patient first to determine their needs and priorities rather than create a care plan without assessment.
B. At least three times during the shift: at the beginning, in the middle, at the end, and as needed. Regular documentation is good practice, but the initial assessment must be documented at the beginning of the shift to establish a baseline.
C. An initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift. Documenting an initial assessment is crucial for identifying immediate needs and planning care, especially after surgery.
D. At the end of the shift so that the nurse can give full attention to the patient's needs during the shift. Waiting until the end of the shift risks missing critical changes and does not provide a clear baseline assessment.
Correct Answer is A
Explanation
A. Tenderness upon palpation and generalized erythema indicate skin irritation and possible sunburn, which are signs of overexposure to PUVA treatment. This finding suggests that the client may have received excessive ultraviolet exposure, leading to skin damage.
B. Thick skin plaques topped by silvery white scales are characteristic of psoriasis vulgaris itself, not a sign of overexposure to PUVA.
C. Requiring sunglasses because sunlight hurts the eyes may indicate sensitivity but is not a specific indicator of overexposure to PUVA treatment; it could relate to other issues such as underlying eye conditions.
D. Brown, rough, greasy, wart-like papules on the face are not typically associated with PUVA overexposure but could be related to other skin conditions or lesions.