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 B

Explanation

A. Hamburger on a bun and a banana: Bananas are high in potassium, which must be restricted in CKD. Processed hamburger meat may also be high in sodium and phosphorus.

B. Spaghetti and meat sauce with breadsticks: Pasta and meat sauce are generally low in potassium and phosphorus if made without salt substitutes. Breadsticks are low in potassium.

C. Carrots and spinach: Spinach is high in potassium and phosphorus. Cooked carrots are borderline and must be portion-controlled.

D. Cold cuts with bun and fresh pears: Cold cuts are typically high in sodium and phosphorus. Pears are generally acceptable, but the entire meal is unsuitable due to the cold cuts.

A. Skin is red, blanches, and weeps B. Skin has a leathery and dry C. Skin is waxy in appearance D. Skin is intact, dry, and red in color

Correct Answer is A

Explanation

A. Skin is red, blanches, and weeps: This is consistent with deep partial-thickness burns. These burns damage deeper layers but still allow capillary refill and exudate.

B. Skin has a leathery and dry: This is characteristic of full-thickness (third-degree) burns.

C. Skin is waxy in appearance: A waxy appearance suggests full-thickness burns.

D. Skin is intact, dry, and red in color: This indicates superficial (first-degree) burns like sunburn.

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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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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.)