A nurse cares for a patient who has cirrhosis of the liver. What action would the nurse take to decrease the presence of ascites?

Choice A reason: Hypokalemia, or low potassium levels, is not typically expected in clients with extensive burn injuries. In fact, during the acute phase of burn injury, hyperkalemia is more common due to the release of potassium from damaged cells and the impairment of kidney function.

Choice B reason: Metabolic alkalosis is not a common finding in clients with extensive burns. Instead, metabolic acidosis is more likely due to the increased production of lactic acid from tissue hypoxia and impaired perfusion. Burn injuries can lead to significant fluid and electrolyte shifts, but metabolic alkalosis is not the usual result.

Choice C reason: Low hemoglobin can occur in burn patients due to fluid shifts and the loss of red blood cells from the injury itself. However, it is not the most characteristic laboratory finding associated with extensive burns compared to hyperkalemia.

Choice D reason: Hyperkalemia is the expected laboratory result in clients with extensive burn injuries. Burns cause massive cell destruction, leading to the release of intracellular potassium into the bloodstream. Additionally, impaired kidney function in the acute phase can further contribute to elevated potassium levels, making hyperkalemia a common and critical concern in burn patients.

Choice A reason: Rechecking all of the patient's vital signs is a good practice, but it is not the priority action in this scenario. The patient's symptoms indicate a potential case of autonomic dysreflexia, a life-threatening condition that requires immediate action to reduce blood pressure and address the cause. Rechecking vital signs alone will not resolve the underlying issue.

Choice B reason: Elevating the patient's knees and lowering the head of the bed is not an appropriate action in this situation. This position could potentially increase intracranial pressure and exacerbate the patient's condition. The focus should be on measures that will help lower the blood pressure and alleviate the symptoms of autonomic dysreflexia.

Choice C reason: The priority action is to elevate the head of the bed immediately and notify the provider. Elevating the head of the bed helps to decrease blood pressure and improve venous return. Promptly notifying the provider ensures that the patient receives timely medical intervention to address the underlying cause of autonomic dysreflexia, which is critical for preventing further complications.

Choice D reason: Administering PRN Tylenol for the patient's headache is not the priority in this situation. While pain management is important, the patient's symptoms suggest a more severe condition (autonomic dysreflexia) that requires immediate attention to lower blood pressure and address the root cause. Pain medication alone will not resolve the underlying issue and could delay necessary interventions.