The nurse is assessing the client with a circumferential burn to the left upper extremity. The nurse anticipates the performance of an escharotomy with which of the following assessment findings?
Loss of distal pulses
Increased capillary refill
Increased sensitivity to pain in the area
Limited range of motion
The Correct Answer is A
A. Loss of distal pulses: Loss of pulses indicates vascular compromise from circumferential edema and rigid eschar, which can rapidly progress to ischemia. This finding signals the need for immediate escharotomy to relieve pressure and restore perfusion to the affected extremity.
B. Increased capillary ref: Prolonged capillary refill can suggest reduced circulation, but it appears earlier and is less definitive than the complete loss of palpable pulses. While concerning, it does not carry the same urgency or confirm the need for surgical decompression.
C. Increased sensitivity to pain in the area: Heightened pain sensitivity may occur as tissues swell, but pain alone does not indicate critical circulatory obstruction. The presence or absence of pain is not a reliable determinant for the need for escharotomy compared with pulse changes.
D. Limited range of motion: Decreased mobility is common with circumferential burns due to stiffness and swelling, but it does not reliably signal vascular compromise. Although it affects function, it is not an indication for emergent escharotomy in the absence of circulatory impairment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. 36%: This would overestimate the burned area. The Rule of Nines assigns 18% to the entire anterior trunk and 9% to each entire arm. Only the anterior surfaces are involved here, so this value is too high.
B. 18%: This only accounts for the anterior trunk. The anterior aspects of both arms add additional surface area, so 18% underestimates the total burned area.
C. 30%: This does not accurately sum the anterior surfaces. Each arm’s anterior surface is approximately 4.5%, and the anterior trunk is 18%, totaling less than 30%.
D. 27%: Using the Rule of Nines, the anterior trunk is 18%, and the anterior surfaces of both arms are 4.5% each (total 9%). Adding these together gives 27%.
Correct Answer is D
Explanation
A. Hyperkalemia and hypernatremia: During the diuretic phase, the kidneys excrete large volumes of urine, leading to loss of potassium and sodium. Hyperkalemia and hypernatremia are more characteristic of the oliguric phase of AKI.
B. Hypokalemia and hypernatremia: Although potassium is lost, sodium loss also occurs during the diuretic phase, making hypernatremia unlikely. Sodium depletion can result from excessive urinary losses.
C. Hyperkalemia and hyponatremia: Hyperkalemia is typically seen in the oliguric phase. In the diuretic phase, potassium is excreted in large amounts, making hypokalemia more common.
D. Hypokalemia and hyponatremia: The diuretic phase causes high urine output with excessive loss of electrolytes. Both potassium and sodium are depleted, putting the client at risk for hypokalemia and hyponatremia. Monitoring and replacement are essential.
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