A client is admitted to the emergency department with a full-thickness burn to the right arm. Upon assessment, the arm is edematous, the fingers are mottled, and the radial pulse is now absent. The client states that the pain is 8/10. What is the priority action the nurse should take?

Instruct the client to exercise the fingers and wrist.

Call the healthcare provider to report the loss of the radial pulse.

Continue to assess the arm every hour for any additional changes.

Administer morphine IV.

Answer and Explanation

The Correct Answer is B

Choice A reason: Instructing the client to exercise the fingers and wrist is not the immediate priority. While maintaining mobility is important in burn care, the absence of a radial pulse indicates a potential vascular compromise that needs urgent attention.

Choice B reason: Calling the healthcare provider to report the loss of the radial pulse is the correct and immediate action. The absence of a radial pulse suggests that the edema is causing compartment syndrome, which can lead to tissue ischemia and necrosis if not promptly treated. This is a medical emergency requiring immediate intervention, possibly including a fasciotomy to relieve pressure.

Choice C reason: Continuing to assess the arm every hour for additional changes is important, but it is not the immediate priority. The absence of a radial pulse indicates a critical issue that needs immediate reporting and intervention, rather than waiting for further changes.

Choice D reason: Administering morphine IV can help manage the client's pain, which is significant at 8/10. However, it does not address the underlying issue of the absent radial pulse and potential compartment syndrome. Pain management is important but secondary to resolving the vascular compromise.

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Correct Answer is D

Explanation

Choice A reason: A low-protein diet can be beneficial in reducing the workload on the kidneys by decreasing the production of waste products that need to be excreted. However, high-potassium intake is not recommended for CKD patients because their kidneys may not efficiently excrete potassium, leading to hyperkalemia, which can be dangerous.

Choice B reason: A diet high in calcium, potassium, and protein is not suitable for CKD patients. Excessive protein can increase the production of waste products, calcium intake needs to be monitored to avoid complications like calcification, and high potassium levels can lead to hyperkalemia. This combination could potentially worsen the patient's condition.

Choice C reason: A high-carbohydrate, high-protein diet is not ideal for CKD patients. While carbohydrates can provide energy, high protein intake increases the load on the kidneys. The goal is to reduce the production of waste products that the kidneys need to filter, so a high-protein diet is counterproductive.

Choice D reason: A low-protein, low-sodium, low-potassium diet is most appropriate for CKD patients. Reducing protein intake decreases the production of waste products, low sodium helps control blood pressure and fluid balance, and low potassium prevents hyperkalemia. This diet helps manage the symptoms and progression of CKD more effectively.

A. Decreased calcium. B. Decreased BUN. C. Decreased hemoglobin. D. Decreased potassium. E. Elevated creatinine. F. Increased phosphorus. G. Decreased glomerular filtration rate (GFR).

Correct Answer is ["A","C","E","F","G"]

Explanation

Choice A reason: Decreased calcium is expected in end-stage chronic kidney disease (CKD) due to impaired kidney function. The kidneys are responsible for converting vitamin D into its active form, which helps in calcium absorption. Reduced kidney function leads to decreased active vitamin D, resulting in lower calcium levels.

Choice B reason: Decreased blood urea nitrogen (BUN) is not typical in CKD. Instead, BUN levels usually increase because the kidneys are less able to remove urea from the blood. Urea is a waste product of protein metabolism, and elevated BUN is indicative of impaired kidney function.

Choice C reason: Decreased hemoglobin is expected in CKD due to reduced production of erythropoietin by the kidneys. Erythropoietin stimulates the production of red blood cells, and a lack of it leads to anemia, reflected by lower hemoglobin levels.

Choice D reason: Decreased potassium is not typically seen in CKD. In fact, potassium levels often increase because the kidneys are less able to excrete it. Hyperkalemia (high potassium) is a common complication in CKD and requires careful monitoring.

Choice E reason: Elevated creatinine is expected in CKD. Creatinine is a waste product of muscle metabolism, and elevated levels indicate impaired kidney function as the kidneys are less able to clear it from the blood.

Choice F reason: Increased phosphorus is a common finding in CKD due to the kidneys' reduced ability to excrete phosphorus. This can lead to hyperphosphatemia, which can cause secondary hyperparathyroidism and further complications.

Choice G reason: Decreased glomerular filtration rate (GFR) is a hallmark of CKD. GFR measures how well the kidneys are filtering blood, and a lower GFR indicates reduced kidney function. It is used to stage the severity of CKD.

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A client is admitted to the emergency department with a full-thickness burn to the right arm. Upon assessment, the arm is edematous, the fingers are mottled, and the radial pulse is now absent. The client states that the pain is 8/10. What is the priority action the nurse should take?

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Naxlex Comprehensive Predictor Exams

The nurse is instructing the client with chronic kidney disease (CKD) to maintain adequate nutritional intake. Which diet would be most appropriate?

Correct Answer is D

Explanation

The 75-year-old client is hospitalized with end-stage chronic kidney disease. Which of the following serum lab findings would the nurse expect? Select all that apply.

Correct Answer is ["A","C","E","F","G"]

Explanation

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