The patient sustained third degree burns to the entirety of bilateral hands and forearms 96 hours ago. Which nursing intervention is most important to ensure the patient is able to keep the hands?

Frequent radial pulse checks. At 96 hours, the patient with burns is past the acute phase. Eschar formation that hardens may lead to compartment syndrome that damages tissue and leads to the loss of limbs. Performing frequent radial pulse checks will allow the nurse to monitor circulation and determine if intervention is necessary. Although strict aseptic technique is required to prevent infection (which can lead to loss of limb) unnoticed loss of circulation will lead to compartment syndrome. Aggressive fluid resuscitation and hourly intake and output measurements will prevent shock and death in the acute phase.

The patient sustained third degree burns to the entirety of bilat...

Category: Reduction of Risk Potential
Difficulty: 9

Topics: Assessment Cardiovascular Delegation, Prioritization and Leadership Inflammation Tissue Integrity

Want help? View the answer with rationale.

Additional Reduction of Risk Potential Questions

An alert patient requires a nasogastric (NG) tube for abdominal decompression. The tube is placed to the appropriate depth, but the nurse is unable to hear a rush of air when auscultating over the patient’s stomach and cannot aspirate gastric contents for pH testing. Which of the following is the most appropriate next course of action?

Question Type: Multiple Choice - Select One
Difficulty: 5

Which is a late sign of hypoxemia?

Question Type: Multiple Choice - Select One
Difficulty: 4

The nurse is reviewing the results of a chromosomal microarray. The results are significant for a chromosomal abnormality in which a single amino acid has been altered. Which of the following terms should the nurse use to describe this abnormality?

Question Type: Multiple Choice - Select One
Difficulty: 4

Show Calculator

Want help? View the answer with rationale.

Rationale

Additional Reduction of Risk Potential Questions

Nursing Careers

Nursing Degrees

NCLEX