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 B
Explanation
A. Bradycardia: Peritonitis is usually associated with tachycardia, not bradycardia.
B. Nausea and vomiting: These are common early signs of peritonitis, often accompanied by abdominal pain and fever.
C. Increased urinary output: Clients with peritoneal dialysis often have reduced kidney function, so urine output is generally decreased, not increased.
D. Hyperactive bowel sounds: Bowel sounds are usually diminished or hypoactive in peritonitis due to inflammation.
Correct Answer is D
Explanation
A. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area.": This describes a skin graft, not escharotomy.
B. "This procedure involves placing the client into a Whirlpool tub and removing the dead tissue.": This describes hydrotherapy or wound debridement.
C. "Dead tissue will be non-surgically removed.": Describes enzymatic or mechanical debridement.
D. "Incisions will be made in the burnt tissues to improve circulation.": Escharotomy relieves pressure caused by tight, burned skin (eschar) to restore blood flow and prevent compartment syndrome.
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