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A nurse is preparing to care for a client after a full thickness chemical burn of the bilateral lower extremities. The nurse is aware that 3rd degree, full thickness burns affect which of the following? Select all that apply.

Muscle layers

Epidermal layers

Dermal layers

Subcutaneous layers

Bone and ligaments

Answer and Explanation

Correct Answer : A,B,C,D

A. Muscle layers: Full-thickness burns may extend into muscle, especially with chemical burns.

B. Epidermal layers: The outermost layer is completely destroyed in full-thickness burns.

C. Dermal layers: Full-thickness burns extend through both the epidermis and dermis.

D. Subcutaneous layers: These burns also involve the subcutaneous fat and connective tissue.

E. Bone and ligaments: Involvement of bone and ligaments would indicate a 4th-degree burn, not 3rd-degree.

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Correct Answer is ["B","C"]

Explanation

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.

A. Decreased serum sodium B. Decreased serum phosphorus C. Decreased urine specific gravity D. Decreased serum potassium

Correct Answer is D

Explanation

A. Decreased serum sodium: Kayexalate exchanges sodium for potassium, so sodium may actually increase.

B. Decreased serum phosphorus: Kayexalate does not directly affect phosphate levels.

C. Decreased urine specific gravity: Kayexalate does not influence urine output or concentration.

D. Decreased serum potassium: Kayexalate treats hyperkalemia by exchanging potassium ions for sodium in the intestines, lowering serum potassium.

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A nurse is preparing to care for a client after a full thickness chemical burn of the bilateral lower extremities. The nurse is aware that 3rd degree, full thickness burns affect which of the following? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.)

Correct Answer is ["B","C"]

Explanation

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Correct Answer is D

Explanation

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