A nurse is conducting an assessment of a client with a severe circumferential burn injury to the forearm. Which of the following assessments should the nurse prioritize?
(Select All that Apply.)
Assessing the client's support system
Assessing and removing any rings or jewelry from affected limb
Assessing the client's circulation distal to the burn site
Assessing the client's urine output
Assessing the client's respiratory function
Correct Answer : B,C
A. Assessing the client's support system: Important in overall care, but not a priority in the acute phase.
B. Assessing and removing any rings or jewelry from affected limb: Jewelry can cause constriction due to swelling; removing it prevents further vascular compromise.
C. Assessing the client's circulation distal to the burn site: Circumferential burns can compromise perfusion due to edema or eschar formation. Checking pulses, cap refill, and sensation is essential.
D. Assessing the client's urine output: Important in systemic burns, but not directly related to a localized forearm burn.
E. Assessing the client's respiratory function: Critical in burns involving the face or inhalation injury, but not the forearm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Urinary output 25 mL/hr: This is below normal, but not an immediate airway threat.
B. Heart rate 122/min: Elevated HR is common in burns due to fluid shifts and stress.
C. Pain of 6 on a scale of 0 to 10: Pain is expected but not life-threatening.
D. Difficulty swallowing secretions: Indicates possible airway edema or inhalation injury, which can progress to airway obstruction. This is a medical emergency.
Correct Answer is D
Explanation
Formula: 4 mL × Body weight (kg) × %TBSA
4 × 100 × 40 = 16,000 mL total in 24 hours
Half (8,000 mL) is given in the first 8 hours
Answer- 8000ml
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