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. "You have a genetic tendency for the development of anemia.”: Anemia in CKD is primarily due to impaired erythropoietin production, not genetics.

B. "The increased metabolic waste products in your body depress the bone marrow and cause anemia.”: While uremic toxins may have some marrow-suppressive effects, the main cause is lack of erythropoietin.

C. "There is a decreased production by the kidneys of the hormone erythropoietin which is the cause of your anemia.”: In CKD, damaged kidneys produce less erythropoietin, leading to reduced RBC production and anemia.

D. "You are not eating enough iron-rich foods, which is causing anemia.”: Although iron deficiency can contribute, this is not the primary cause in CKD-related anemia.

A. A combination of benzodiazepines and topical anesthetics B. The use of oral opioids C. A patient-controlled analgesia (PCA) system D. Distraction and relaxation techniques

Correct Answer is C

Explanation

A. A combination of benzodiazepines and topical anesthetics: This is not effective for the deep and constant pain experienced with burns.

B. The use of oral opioids: Absorption may be delayed or unpredictable in critically ill burn clients.

C. A patient-controlled analgesia (PCA) system: PCA provides rapid and individualized control of pain, which is essential in the acute phase.

D. Distraction and relaxation techniques: These are supportive, not primary, strategies for severe pain.

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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.)