The nurse is reviewing laboratory values for a patient receiving treatment during the emergent phase of burn management. Which laboratory result should the nurse expect for the patient at this time:
Increased hematocrit
Decreased blood urea nitrogen (BUN)
Decreased serum potassium
increased serum albumin
The Correct Answer is A
Choice A rationale: During the emergent phase of burn management, patients commonly experience hemoconcentration due to fluid shift from the intravascular space to the interstitial space. This leads to an increase in hematocrit, indicating a higher concentration of red blood cells in the blood.
Choice B rationale: Burn injuries often result in increased protein breakdown and an elevation in BUN levels.
Choice C rationale: Burn injuries can cause the release of potassium from damaged cells, leading to hyperkalemia rather than hypokalemia.
Choice D rationale: The emergent phase of burn management is characterized by a decrease in serum albumin due to protein loss from the burned tissue and increased capillary permeability.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale: The nurse should not include any opinions, judgments, or blame in the incident report, as this could be used as evidence in a legal case. Therefore, the nurse should not question the charge nurse about care deficits.
Choice B rationale: The nurse should not include any opinions, judgments, or blame in the incident report, as this could be used as evidence in a legal case. Therefore, the nurse should not document what the nurse believes was the cause of ulcer development.
Choice C rationale: This is important because it provides factual information about the client's condition and perception of the event, which could help in identifying the factors that contributed to the ulcer development and preventing further complications.
Choice D rationale: Documenting in the client's medical record that the nurse completed an incident report is not the primary purpose of the incident report itself. Incident reports are internal documents used by the healthcare facility to track and investigate events. The documentation in the client's medical record should focus on the client's clinical condition, care provided, and response to treatment.
Correct Answer is C
Explanation
Choice A rationale: tachycardia is an expected finding in burns patients due to the increase in metabolic rate and fluid loss.
Choice B rationale: a urine output of 25 ml/hr is too low for an individual with burns hence the need for adequate fluid resuscitation. However, this is not a priority sign compared with the difficulty in breathing.
Choice C rationale: difficulty in swallowing is an indicator of airway edema which may compromise the patients breathing and oxygenation which may result in death. Therefore, the healthcare provider should be notified to assess the need for intubation.
Choice D rationale: Pain of 6 on a scale of 0 to 10 is moderate and is expected due to burns and can be managed with analgesics and nonpharmacological interventions.
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