A nurse is caring for a client with 45% total body surface area (TBSA) thermal burns. During the emergent, initial phases of burn shock the nurse should closely monitor for which electrolyte imbalance?
Hyperkalemia
Hypokalemia
Hypernatremia
Hypocalcemia
The Correct Answer is A
A. Hyperkalemia: During the emergent phase, massive cell injury causes potassium to leak into the extracellular space, raising serum K+ levels.
B. Hypokalemia: More common later in the fluid resuscitation or diuretic phase.
C. Hypernatremia: Sodium is often lost into burned tissues or with fluid shifts; hyponatremia may be seen early.
D. Hypocalcemia: While possible, especially if blood products are given, hyperkalemia is more prominent early.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Low serum albumin: While low albumin indicates poor nutrition or liver disease, it's not a direct cause of AKI.
B. Renal Calculi: Can cause obstruction in the urinary tract, leading to post-renal AKI.
C. Hypertension: Chronic high BP damages renal vasculature, increasing AKI risk.
D. Hypovolemia: Decreased perfusion leads to prerenal AKI.
E. Ineffective wound healing: Indicates poor nutrition or infection, but is not a primary AKI risk factor.
Correct Answer is ["A","B","C","D"]
Explanation
A. Muscle layers: Full-thickness burns may extend into muscle, especially with chemical burns.
B. Epidermal layers: The outermost layer is completely destroyed in full-thickness burns.
C. Dermal layers: Full-thickness burns extend through both the epidermis and dermis.
D. Subcutaneous layers: These burns also involve the subcutaneous fat and connective tissue.
E. Bone and ligaments: Involvement of bone and ligaments would indicate a 4th-degree burn, not 3rd-degree.
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