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 ["A","C","D","E"]

Explanation

A. Ensure NPO status: The client is kept NPO before the biopsy to reduce the risk of aspiration if sedation is used.

B. Administer diphenhydramine (Benadryl) prior to procedure: This is not routine for kidney biopsy unless the client has allergies or specific indications.

C. Obtain coagulation studies: Important to assess for bleeding risk because kidney biopsies have a high bleeding potential.

D. Verify informed consent: This is essential before any invasive procedure.

E. Collect a urine specimen prior to procedure: A pre-procedure urine sample is collected for baseline comparison.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Critical to assess: A. Airway patency and signs of inhalation injury

Clients in enclosed-space fires are at high risk for inhalation injury, which can lead to airway edema and obstruction. This is the first priority.

Critical assessment finding: C. Singed nasal hairs and soot around the nares

These are hallmark signs of possible inhalation injury and may indicate airway compromise even before symptoms become severe.

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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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Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for the operating room Exhibits A nurse is planning care for a client who is scheduled to have a kidney biopsy. Which of the following interventions should the nurse include in the plan? (Select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

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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.)