A nurse is caring for a client who has burns to approximately 50% of their body. Which of the following physiological changes related to the burns should the nurse anticipate? Select all that apply.

Hypermagnesemia

Capillary leak

Loss of protein

Diuresis

Decreased plasma volume

Answer and Explanation

Correct Answer : B,C,E

A. Hypermagnesemia: Hypermagnesemia is not typically seen in burn patients. More commonly, patients may experience imbalances in electrolytes such as sodium or potassium. Hypermagnesemia is not directly associated with burns or their complications.

B. Capillary leak: In the immediate aftermath of a severe burn, the damage to the capillaries leads to a capillary leak, where plasma, proteins, and electrolytes seep out of the vessels and into the interstitial space. This results in edema and a significant reduction in circulating blood volume.

C. Loss of protein: Burn injuries, especially those affecting a large body surface area, cause significant loss of proteins (mainly albumin) due to the breakdown of the skin and increased capillary permeability. This loss of protein contributes to the development of edema and hypovolemic shock.

D. Diuresis: Diuresis does not typically occur in the immediate post-burn period. During the first 24-48 hours, oliguriaoccurs due to hypovolemia and kidney perfusion problems. Diuresis occurs after fluid resuscitation has been successful and fluid begins to shift back from the interstitial space into the vascular system.

E. Decreased plasma volume: A reduction in plasma volume is a critical concern in burn patients due to fluid and protein loss from the damaged blood vessels. This leads to hypovolemia, which requires aggressive fluid resuscitation to prevent shock and organ failure.

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Correct Answer is A

Explanation

A. Wash hands with soap and water: Soap and water are the most effective method for removing Clostridium difficile spores from the hands. Alcohol-based hand sanitizers are ineffective against C. difficile spores, so washing with soap and water is the priority.

B. Don a clean pair of nonsterile gloves: While donning new gloves is important for continuing care, it does not address the need to properly disinfect hands after a contamination event, which should be done immediately.

C. Wash hands with alcohol-based hand sanitizer: Alcohol-based hand sanitizers are not effective against C. difficile spores, so they should not be used in this scenario. Soap and water are required to effectively remove the spores.

D. Wash hands with a bleach wipe from a nearby container: While bleach wipes are effective for disinfecting surfaces, they are not intended for hand hygiene. Soap and water should be used to clean hands in this situation.

A. Intact skin with localized erythema. B. Partial-thickness skin loss with red tissue in wound bed. C. Full thickness skin loss with visible bone D. Full thickness skin loss with visible adipose tissue.

Correct Answer is B

Explanation

A. Intact skin with localized erythema: This description aligns more with stage 1 pressure injuries, where there is non-blanchable erythema without any skin breakdown.

B. Partial-thickness skin loss with red tissue in wound bed: Stage 2 pressure injuries involve partial-thickness skin loss, which may affect the epidermis and possibly the dermis. The wound bed typically shows red, viable tissue, and may present as a shallow open ulcer with a pink or red wound bed.

C. Full thickness skin loss with visible bone: This describes a stage 4 pressure injury, where there is full-thickness tissue loss with exposed bone, tendon, or muscle.

D. Full thickness skin loss with visible adipose tissue: This describes a stage 3 pressure injury, where there is full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, but without exposure of bone or muscle.

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A nurse is caring for a client who has burns to approximately 50% of their body. Which of the following physiological changes related to the burns should the nurse anticipate? Select all that apply.

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