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 C

Explanation

A. Hypomagnesemia: Magnesium levels are typically elevated in AKI due to reduced excretion.

B. Decreased creatinine level: Creatinine rises during the oliguric phase due to decreased filtration.

C. Hyperkalemia: Potassium accumulates in the blood during oliguria due to impaired excretion.

D. Increased glomerular filtration rate (GFR): GFR is decreased in AKI.

A. Administering sodium polystyrene sulfonate. B. Initiating an IV potassium infusion. C. Administering a potassium-sparing diuretic. D. Encouraging the client to eat bananas.

Correct Answer is A

Explanation

A. Administering sodium polystyrene sulfonate:
This medication removes potassium through the GI tract and is used to treat hyperkalemia.

B. Initiating an IV potassium infusion:
The client already has hyperkalemia; giving potassium would worsen it.

C. Administering a potassium-sparing diuretic:
These medications retain potassium and would further elevate potassium levels.

D. Encouraging the client to eat bananas:
Bananas are high in potassium and should be avoided in hyperkalemia.

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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.)