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 C
Explanation
A. Hypomagnesemia: Magnesium levels are typically elevated in AKI due to reduced excretion.
B. Decreased creatinine level: Creatinine rises during the oliguric phase due to decreased filtration.
C. Hyperkalemia: Potassium accumulates in the blood during oliguria due to impaired excretion.
D. Increased glomerular filtration rate (GFR): GFR is decreased in AKI.
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