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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
A. Ensure NPO status: The client is kept NPO before the biopsy to reduce the risk of aspiration if sedation is used.
B. Administer diphenhydramine (Benadryl) prior to procedure: This is not routine for kidney biopsy unless the client has allergies or specific indications.
C. Obtain coagulation studies: Important to assess for bleeding risk because kidney biopsies have a high bleeding potential.
D. Verify informed consent: This is essential before any invasive procedure.
E. Collect a urine specimen prior to procedure: A pre-procedure urine sample is collected for baseline comparison.
Correct Answer is ["A","D","E"]
Explanation
A. Blistering of area: Blisters are characteristic of superficial partial-thickness burns, involving the epidermis and part of the dermis.
B. Dry crusting surface: This is more typical of deeper burns; partial-thickness burns are moist.
C. Intact skin surface: The skin is not intact; it is damaged and blistered.
D. Blanching of wound area: Indicates intact capillary refill and superficial depth.
E. Pain at wound site: Nerve endings are exposed, making these burns very painful.
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