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.)
Decreased plasma volume
Diuresis
Hypermagnesemia
Capillary leak
Loss of protein
Correct Answer : A,D,E
A. Decreased plasma volume: Burn injuries cause a significant inflammatory response, leading to fluid shifts from the intravascular space to the interstitial space. This results in hypovolemia and decreased plasma volume, especially during the acute phase of burns.
B. Diuresis: Diuresis typically occurs after fluid resuscitation and stabilization of the client (in the later phase of burn recovery). In the initial phase, oliguria is more common due to hypovolemia and reduced renal perfusion.
C. Hypermagnesemia: Hypermagnesemia is not typically associated with burn injuries. Instead, clients with burns often experience hypomagnesemia due to fluid shifts, protein loss, and increased renal losses.
D. Capillary leak: Burn injuries lead to a systemic inflammatory response, causing capillary leak syndrome. This increases vascular permeability, allowing fluid, electrolytes, and proteins to leak into the interstitial spaces, contributing to edema and hypovolemia.
E. Loss of protein: Proteins are lost through damaged capillaries and open burn wounds, contributing to decreased oncotic pressure, edema, and a need for aggressive nutritional support to promote healing and recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assess the patient’s respiratory rate, rhythm, depth:
This is the correct action to take first. Hypokalemia can lead to respiratory muscle weakness, which can result in respiratory compromise or failure. Assessing the patient's respiratory rate, rhythm, and depth will help determine if there are any signs of respiratory distress or impending respiratory failure.
B. Call the healthcare provider:
While it's important to involve the healthcare provider, especially if there is a significant change in the patient's condition, assessing the patient's immediate respiratory status takes priority to ensure prompt intervention if respiratory distress is present.
C. Document findings and monitor the patient:
Documenting findings and ongoing monitoring are essential steps, but they come after addressing the patient's immediate needs, such as assessing respiratory status in this case.
D. Measure the patient’s pulse and blood pressure:
While vital signs are important, they may not immediately address the potential respiratory compromise associated with hypokalemia-induced muscle weakness. Assessing respiratory status is more directly relevant to the observed change in handgrip strength.
Correct Answer is D
Explanation
A. Stage III pressure injury
Stage III pressure injuries involve full-thickness skin loss, extending into the subcutaneous tissue but not through the fascia. These wounds typically present as deep craters and may involve undermining or tunneling. Non-blanchable erythema alone without visible skin loss is not characteristic of a Stage III pressure injury.
B. Stage IV pressure injury
Stage IV pressure injuries are the most severe and involve full-thickness tissue loss with exposed bone, tendon, or muscle. These wounds often have extensive tissue damage and can be difficult to manage. Again, non-blanchable erythema without visible skin loss is not indicative of a Stage IV pressure injury.
C. Stage II pressure injury
Stage II pressure injuries involve partial-thickness skin loss with damage to the epidermis and possibly the dermis. These wounds often present as shallow open ulcers or blisters and may have characteristics such as intact or ruptured blisters. While Stage II injuries can present with erythema, non-blanchable erythema specifically indicates a Stage I injury.
D. Stage I pressure injury
Stage I pressure injuries are the earliest stage and involve non-blanchable erythema of intact skin. The skin may be warmer or cooler than surrounding tissue and may have changes in sensation. There is no visible skin loss at this stage, but the area is at risk for further injury if pressure is not relieved. Therefore, non-blanchable erythema on the heels most likely indicates a Stage I pressure injury.
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