A nurse is caring for a client with 45% total body surface area (TBSA) thermal burns. During the emergent, initial phases of burn shock the nurse should closely monitor for which electrolyte imbalance?

Hyperkalemia

Hypokalemia

Hypernatremia

Hypocalcemia

Answer and Explanation

The Correct Answer is A

A. Hyperkalemia: During the emergent phase, massive cell injury causes potassium to leak into the extracellular space, raising serum K+ levels.

B. Hypokalemia: More common later in the fluid resuscitation or diuretic phase.

C. Hypernatremia: Sodium is often lost into burned tissues or with fluid shifts; hyponatremia may be seen early.

D. Hypocalcemia: While possible, especially if blood products are given, hyperkalemia is more prominent early.

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Correct Answer is D

Explanation

A. Bleeding may occur at injection sites when the intramuscular route is used: While possible, this is not the primary concern.

B. The client can experience nausea and vomiting when given oral medications: This may be true but is secondary to absorption issues.

C. Pain resulting from a burn injury requires relief by the fastest route available: Although IV is fast, the key issue is absorption.

D. Damaged tissue and edema may interfere with drug absorption via other routes: Burned and edematous tissue reduces IM and subcutaneous absorption, making IV the preferred route.

A. Encourage the client to cough and auscultate the lungs again. B. Document the change and continue to monitor the client's respiratory rate. C. Notify the health care provider and prepare for endotracheal intubation. D. Reposition the client in high-Fowler's position and reassess breath sounds.

Correct Answer is C

Explanation

A. Encourage the client to cough and auscultate the lungs again:
This delays necessary intervention and is not appropriate for suspected airway compromise.

B. Document the change and continue to monitor the client's respiratory rate:
Passive monitoring is not safe here given signs of impending respiratory failure.

C. Notify the health care provider and prepare for endotracheal intubation:
Facial burns and decreasing breath sounds suggest airway edema—immediate intubation is critical before complete airway obstruction.

D. Reposition the client in high-Fowler's position and reassess breath sounds:
While positioning helps breathing, it’s not sufficient or timely enough in a rapidly deteriorating airway.

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A nurse is caring for a client with 45% total body surface area (TBSA) thermal burns. During the emergent, initial phases of burn shock the nurse should closely monitor for which electrolyte imbalance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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