The nurse is preparing to assist the burn surgeon in performing an escharotomy for a patient who has full-thickness circumferential burns that resulted in compartment syndrome. The nurse understands that the expected outcome of this procedure is to:

Enhance the formation of granulation tissue.

Ensure brisk bleeding from the sites so ﬂuid volume status can be maintained.

Ensure the return of distal pulses.

Decrease edema formation.

Answer and Explanation

The Correct Answer is C

Choice A reason: Enhancing the formation of granulation tissue is not the immediate expected outcome of an escharotomy.

Choice B reason: Ensuring brisk bleeding is not the goal; minimal bleeding is expected, and it should be controlled to maintain ﬂuid volume status.

Choice C reason: Ensuring the return of distal pulses is the expected outcome of an escharotomy, as it relieves pressure and restores circulation to the aﬀected limbs.

Choice D reason: Decreasing edema formation is a benefit of the procedure but not the primary expected outcome.

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Correct Answer is D

Explanation

Choice A reason: Urine output is important but not the priority after administration of fibrinolytic medication.

Choice B reason: Vital signs are routinely monitored but the priority is assessing for any signs of complications from the medication, such as bleeding or stroke.

Choice C reason: The name of the patient's dog is irrelevant to the patient's medical care and assessment.

Choice D reason: Neurological status is the priority to monitor for signs of intracranial hemorrhage, a potential complication of fibrinolytic therapy.

A. The client has at least one stool per day. B. The client denies nausea and vomiting (N/V). C. The client's bilirubin level decreases. D. The client is alert and oriented (A&Ox4).

Correct Answer is D

Explanation

Choice A reason: While having at least one stool per day is a sign that lactulose is working, it does not directly indicate its eﬀectiveness in reducing ammonia levels and improving mental status.

Choice B reason: Denial of nausea and vomiting is positive but is not a direct indicator of lactulose's eﬀectiveness in treating hepatic encephalopathy.

Choice C reason: A decrease in bilirubin levels may be a positive sign, but it is not a direct indicator of lactulose's eﬀectiveness in treating hepatic encephalopathy.

Choice D reason: The client being alert and oriented is a direct indicator that lactulose is eﬀectively reducing ammonia levels and improving mental status, which is a key goal in treating hepatic encephalopathy associated with liver cirrhosis.

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The nurse is preparing to assist the burn surgeon in performing an escharotomy for a patient who has full-thickness circumferential burns that resulted in compartment syndrome. The nurse understands that the expected outcome of this procedure is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse receives a patient from the emergency department following administration of a fibrinolytic medication, TPA, for a large anterior wall myocardial infarction. The priority assessment for this patient would be which of the following?

Correct Answer is D

Explanation

Which of the following indicate to the nurse that lactulose is eﬀective for an older adult who has advanced liver cirrhosis?

Correct Answer is D

Explanation

Which action should the nurse take first when a patient is seen in the outpatient clinic with neck pain?

The normal PR interval is:

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In planning care for a patient with acute myocardial infarction (AMI), which of the following should the nurse identify as the highest priority goal of care?

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