A nurse in an emergency room is caring for a client who sustained deep partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

Draw blood for a complete blood cell (CBC) count.

Inspect the mouth for signs of inhalation injuries.

Administer intravenous pain medication.

Insert an indwelling urinary catheter.

Answer and Explanation

The Correct Answer is B

A. Draw blood for a CBC: Important, but not the priority.

B. Inspect the mouth for signs of inhalation injuries: Airway assessment is always the priority in facial/chest burns due to the risk of inhalation injury and impending airway compromise.

C. Administer intravenous pain medication: Important, but airway always comes first.

D. Insert an indwelling urinary catheter: Urine output monitoring is important for fluid resuscitation but follows airway stabilization.

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Correct Answer is A

Explanation

A. Hyperkalemia: In AKI, the kidneys cannot excrete potassium efficiently, leading to elevated potassium levels.

B. Hypernatremia: More common in dehydration but not typically associated with prerenal AKI, where sodium may actually be low due to dilution.

C. Hypophosphatemia: Phosphate tends to increase due to impaired excretion in AKI, not decrease.

D. Hypercalcemia: Calcium levels tend to decrease in AKI due to phosphate retention and reduced vitamin D activation.

A. Place the drainage bag above the level of the client's abdomen. B. Warm the dialysate solution prior to instillation. C. Monitor vital signs every 2 hours during the procedure. D. Maintain the client in a left lateral position during dialysis.

Correct Answer is B

Explanation

A. Place the drainage bag above the level of the client's abdomen: This would impede drainage by gravity. The drainage bag should be below abdominal level to promote outflow.

B. Warm the dialysate solution prior to instillation: Warming the solution enhances diffusion, promotes comfort, and prevents abdominal cramping. Use a warming pad, not a microwave.

C. Monitor vital signs every 2 hours during the procedure: While vital signs are monitored, more frequent monitoring is often required during the initial phase or if the patient is unstable.

D. Maintain the client in a left lateral position during dialysis: The semi-Fowler’s position is preferred to facilitate flow and lung expansion, not lateral positioning.

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A nurse in an emergency room is caring for a client who sustained deep partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

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