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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Orange juice: Does not affect cyclosporine metabolism.
B. Bananas: No known interaction with cyclosporine.
C. Grapefruit juice: Inhibits CYP3A4 enzyme in the liver, which increases cyclosporine levels, leading to toxicity.
D. Smoked salmon: May contain sodium but does not interact with cyclosporine metabolism.
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.
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