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: While blood pressure is important, hyperkalemia can cause cardiac dysrhythmias, making the pulse rate the first assessment to ensure the patient's immediate safety.

Choice B reason: Temperature is not directly aﬀected by serum potassium levels and is not the priority in hyperkalemia.

Choice C reason: Respirations are less likely to be aﬀected immediately by hyperkalemia compared to cardiac function.

Choice D reason: A high serum potassium level can lead to life-threatening cardiac arrhythmias, so assessing the pulse rate is the most critical initial action.

A. A client who told an assistive personnel he is short of breath B. A client who has a prescription for discharge C. A client who received oral pain medication 30 minutes ago D. A client who is scheduled for an abdominal x-ray and is awaiting transport

Correct Answer is A

Explanation

Choice A reason (client care): A client reporting shortness of breath may be experiencing a life-threatening situation that aligns with the ABCs (Airway, Breathing, Circulation) of patient prioritization. This client requires immediate assessment and intervention.

Choice B reason (client care): While discharge is important, it does not take precedence over a client with potential respiratory distress.

Choice C reason (client care): A client who received pain medication 30 minutes ago is likely stable and can be seen after more urgent cases are addressed.

Choice D reason (client care): A client waiting for an abdominal x-ray is not a priority over a client with respiratory issues.

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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

A male client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should nurse Olivia assess first?

Correct Answer is D

Explanation

A nurse is prioritizing client care after receiving a change-of-shift report. Which of the following clients should the nurse plan to see first?

Correct Answer is A

Explanation

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