When caring for a client with full-thickness burns to both lower extremities, which assessment finding(s) warrant immediate intervention by the nurse? (Select all that apply.)

Sloughing tissue around wound edges.

Change in the quality of the peripheral pulses.

Weeping serosanguineous fluid from wounds.

Loss of sensation to the left lower extremity.

Complaint of increased pain and pressure.

Answer and Explanation

Correct Answer : B,D,E

These findings suggest potential complications and compromise to the client's circulation and nerve function, which require immediate attention.

Changes in the quality of peripheral pulses indicate alterations in blood flow and may suggest vascular compromise or decreased perfusion to the affected areas. This finding requires immediate intervention to prevent further damage and ensure adequate blood supply to the extremities.

Loss of sensation to the left lower extremity can be indicative of nerve injury or impaired peripheral nerve function. It is important to assess for nerve damage and address it promptly to prevent complications and maximize the client's recovery.

Complaints of increased pain and pressure are concerning because they may indicate the development of compartment syndrome, a serious complication in which pressure within the muscles and tissues builds up to dangerous levels. Prompt intervention is necessary to relieve the pressure and prevent tissue damage.

While sloughing tissue around wound edges and weeping serosanguineous fluid from wounds are important assessment findings in the context of burn care, they do not require immediate intervention compared to the findings mentioned above. These findings should still be addressed and managed appropriately, but they are not considered immediate emergencies.

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Correct Answer is A

Explanation

Allen's test is a procedure used to assess the patency of the ulnar artery and the collateral circulation of the hand. It is performed to determine the adequacy of collateral circulation before obtaining arterial blood gases from the radial artery. The test helps ensure that the ulnar artery is functioning properly and can supply blood to the hand if the radial artery is used for blood sampling or other invasive procedures.

The test involves occluding both the ulnar and radial arteries while the patient clenches their fist. The nurse then releases pressure on the ulnar artery while maintaining occlusion of the radial artery. The hand should quickly regain normal coloration, indicating adequate collateral circulation.
It's important to note that the Allen's test is specific to the assessment of collateral circulation in the hand and is not used for other purposes such as assessing deep vein thrombosis, cardiac output calculation, or obtaining pulmonary artery pressures.

A. Clients who incurred disease complications promptly received rehabilitation. B. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign. C. At-risk clients received an increased number of routine health screenings. D. Clients reported having new confidence in making healthy food choices.

Correct Answer is A

Explanation

Tertiary prevention programs focus on minimizing the impact of an existing disease or condition and preventing further complications or disability. In the context of cardiovascular disease, one of the goals of tertiary prevention is to provide prompt rehabilitation for clients who have incurred disease complications.

By ensuring that clients who experience complications promptly receive rehabilitation services, the program is effectively addressing the needs of these clients and providing appropriate interventions to minimize the long-term impact of the disease. This outcome indicates that the program is successful in providing the necessary care and support to clients with cardiovascular disease.

Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign focuses on primary prevention rather than tertiary prevention.

At-risk clients receiving an increased number of routine health screenings may be an indicator of improved secondary prevention efforts, but it does not specifically measure the effectiveness of the tertiary prevention program for clients with cardiovascular disease.

Clients reporting new confidence in making healthy food choices is a positive outcome but does not directly reflect the effectiveness of the tertiary prevention program for cardiovascular disease.

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When caring for a client with full-thickness burns to both lower extremities, which assessment finding(s) warrant immediate intervention by the nurse? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When should the nurse conduct an Allen's test?

Correct Answer is A

Explanation

The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicates the program is effective?

Correct Answer is A

Explanation

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

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