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

Answer and Explanation

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.

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Correct Answer is ["A","B","C","D"]

Explanation

A. Muscle layers: Full-thickness burns may extend into muscle, especially with chemical burns.

B. Epidermal layers: The outermost layer is completely destroyed in full-thickness burns.

C. Dermal layers: Full-thickness burns extend through both the epidermis and dermis.

D. Subcutaneous layers: These burns also involve the subcutaneous fat and connective tissue.

E. Bone and ligaments: Involvement of bone and ligaments would indicate a 4th-degree burn, not 3rd-degree.

A. Auscultate the antecubital fossa using a Doppler stethoscope. B. Measure the client's blood pressure to ensure it is higher in the left arm than the right. C. Auscultate the site for a bruit. D. Check the brachial and radial pulses of the left arm simultaneously.

Correct Answer is C

Explanation

A. Auscultate the antecubital fossa using a Doppler stethoscope: The graft is located in the forearm, not the antecubital fossa.

B. Measure the client's blood pressure to ensure it is higher in the left arm than the right: This does not assess AV graft patency and blood pressure should be avoided in the arm with a graft.

C. Auscultate the site for a bruit: The presence of a bruit and thrill indicates blood flow through the graft, confirming patency.

D. Check the brachial and radial pulses of the left arm simultaneously: While peripheral pulses can offer some insight, they do not directly confirm graft patency.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to care for a client after a full thickness chemical burn of the bilateral lower extremities. The nurse is aware that 3rd degree, full thickness burns affect which of the following? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?

Correct Answer is C

Explanation

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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.)