A client with an electrical burn is brought to the emergency department. The entrance wound is on the right hand and the exit wound is on the left foot.
The client reports chest tightness and feels lightheaded. Which action should the nurse take?

This scenario involves metabolic complications following chemotherapy for high-grade malignancies. Knowledge of intracellular electrolyte release, nucleic acid breakdown, and the resulting renal and systemic impacts is required to identify the specific oncological emergency occurring during rapid cell lysis.

Choice A rationale

Gastric ulcers cause abdominal pain and potential bleeding but do not account for a rapid increase in serum uric acid. Uric acid elevation is a systemic metabolic event related to DNA breakdown, whereas ulcers are localized mucosal erosions.

Choice B rationale

Tumor lysis syndrome occurs when chemotherapy causes rapid destruction of malignant cells, releasing intracellular contents. This leads to hyperuricemia, hyperkalemia, and hyperphosphatemia. High uric acid levels (above 6 mg/dL) can cause acute renal failure due to crystal formation.

Choice C rationale

While acute kidney injury may result from tumor lysis syndrome, it is a secondary consequence of the metabolic derangement. The primary diagnosis explaining the constellation of rapid uric acid rise and chemotherapy timing is the lysis syndrome.

Choice D rationale

Gastroenteritis causes nausea and abdominal pain but does not explain the significant metabolic shift of elevated uric acid. It is typically an infectious or inflammatory condition of the digestive tract, not a systemic response to cytotoxic therapy.

Nursing prioritization relies on the ABC framework and identifying the most immediate threat to life. Knowledge of electrolyte imbalances and cardiac conduction must be applied here to recognize that severe hyperkalemia poses an imminent risk of lethal cardiac arrhythmias.

Choice A rationale

A low grade fever of 38.2 C on the first postoperative day is common due to the inflammatory response or atelectasis. While it requires monitoring and lung expansion exercises, it is not an immediate life threat.

Choice B rationale

Severe abdominal pain and nausea are classic symptoms of acute pancreatitis. While the patient is in significant distress and needs analgesia, this presentation is expected for the diagnosis and is second to cardiovascular instability.

Choice C rationale

Confusion and asterixis in cirrhosis indicate hepatic encephalopathy due to elevated ammonia. Normal ammonia is 15 to 45 mcg/dL. This requires treatment with lactulose but is less immediately fatal than a cardiac arrest.

Choice D rationale

A potassium level of 6.8 mEq/L is critically high, as the normal range is 3.5 to 5.0 mEq/L. Peaked T waves indicate myocardial irritability, which can progress rapidly to ventricular fibrillation or asystole, requiring emergent intervention..