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","E"]

Explanation

A. Raisins: Dried fruits like raisins are concentrated sources of potassium and should be avoided in CKD.

B. Bananas: Bananas are high in potassium and commonly restricted in CKD to prevent hyperkalemia.

C. Green beans: Green beans are relatively low in potassium and generally safe for a renal diet.

D. Asparagus: Asparagus has moderate potassium levels but can be included in moderation depending on the client's labs.

E. Tomatoes: Tomatoes, especially in processed forms like sauce or juice, are high in potassium.

A. Client with partial and deep partial thickness burns on the face and neck with high-pitched respiratory sounds B. Client with facial burns and expectorating sooty secretions in no distress C. Client with dry, black skin on both hands and a history of diabetes mellitus D. Client with moist blisters over the back and who reports pain as 10

Correct Answer is A

Explanation

A. Client with partial and deep partial thickness burns on the face and neck with high-pitched respiratory sounds: High-pitched respiratory sounds (stridor) suggest impending airway obstruction, which is life-threatening and requires immediate intervention.

B. Client with facial burns and expectorating sooty secretions in no distress: At risk for inhalation injury but not in immediate respiratory distress.

C. Client with dry, black skin on both hands and a history of diabetes mellitus: Eschar and possible full-thickness burns are serious but not immediately life-threatening compared to airway compromise.

D. Client with moist blisters over the back and who reports pain as 10: Pain is expected and manageable; airway takes priority.

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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.)

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Correct Answer is ["A","B","E"]

Explanation

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Correct Answer is A

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.)