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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The recovery position is not typically recommended for patients with acute pulmonary edema as it does not facilitate optimal breathing.
Choice B reason: The prone position is not generally recommended for acute pulmonary edema as it may not aid in improving oxygenation or breathing.
Choice C reason: The sitting up position, especially at an angle of 45 degrees or greater, is recommended for patients with acute pulmonary edema as it helps to facilitate breathing and decrease venous return to the heart.
Choice D reason: The Trendelenburg position is not recommended for acute pulmonary edema as it can increase the pressure in the chest and worsen breathing difficulties.
Correct Answer is C
Explanation
Choice A reason: Taking several deep breaths is not specifically related to the preparation for a renal system physical assessment. Deep breaths are more commonly associated with lung examination or to help the patient relax.
Choice B reason: Drinking several glasses of water before a renal assessment could potentially fill the bladder, which might interfere with palpation of the kidneys and make it uncomfortable for the patient.
Choice C reason: Emptying the bladder is the correct action before a renal system physical assessment. It allows for better palpation of the kidneys and other structures without the discomfort of a full bladder. It also prevents the possibility of the patient urinating involuntarily during the examination due to a full bladder.
Choice D reason: Providing a urine sample might be part of the overall renal assessment, but it is not necessary to do so immediately before the physical examination of the renal system. The sample can be collected at any time before or after the physical examination.
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