A patient with full-thickness burns over 40 Which complication is vital for the nurse to anticipate and monitor?

Hypokalemia.

Hypothermia.

Hypoglycemia.

Hypertension.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While electrolyte imbalances occur in burn victims, hyperkalemia is actually more common in the acute phase due to massive cell lysis and the release of intracellular potassium into the extracellular space. Hypokalemia might occur later during the diuretic phase or due to gastrointestinal losses. The normal serum potassium range is 3.5 to 5.0 mEq/L. Monitoring potassium is vital, but the immediate threat to metabolic stability in a large surface area burn is the loss of thermoregulation rather than a decrease in potassium.

Choice B rationale

The skin is the primary organ for thermoregulation. With 40 percent full thickness burns, the client loses the ability to prevent evaporative heat loss and maintain a stable core temperature. Hypothermia can lead to coagulopathy, cardiac arrhythmias, and impaired wound healing. The nurse must anticipate this because the loss of the epidermal barrier and the administration of large volumes of room temperature fluids significantly increase the risk. Maintaining a warm environment and using warmed fluids are standard burn protocols.

Choice C rationale

Hypoglycemia is not a typical primary complication of acute burn injury. In fact, the stress response associated with major burns often leads to the release of catecholamines and cortisol, which cause hyperglycemia through increased gluconeogenesis and glycogenolysis. While metabolic demands are extremely high and nutritional support is eventually needed, the immediate physiological threat is not a drop in blood glucose. Normal fasting blood glucose ranges from 70 to 100 mg/dL, but burn patients often require insulin for stress induced elevations.

Choice D rationale

Hypertension is unlikely in the early stages of a 40 percent burn. The more significant risk is burn shock, which is characterized by hypotension due to massive fluid shifts from the intravascular space to the interstitial space. This capillary leak results in decreased cardiac output and low blood pressure. Monitoring for hypotension and signs of poor organ perfusion is a priority during fluid resuscitation. Hypertension would be an unusual finding unless the client had pre-existing cardiovascular disease.

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Correct Answer is D

Explanation

Choice A rationale

Pallor on elevation of the extremity is a classic sign of peripheral arterial disease, not chronic venous insufficiency. When an limb with arterial blockages is raised, gravity hinders the already compromised blood flow, leading to a pale appearance. In contrast, venous insufficiency involves difficulty returning blood to the heart, which usually results in congestion and edema rather than pallor. This clinical finding helps differentiate between the various types of peripheral vascular disorders.

Choice B rationale

Intermittent claudication is characterized by muscle pain or cramping during exercise that is relieved by rest, and it is a hallmark symptom of arterial insufficiency. It occurs when the arterial supply cannot meet the increased metabolic demand of the muscles. Patients with chronic venous insufficiency typically experience a dull ache or heaviness that worsens with prolonged standing rather than sharp exertional pain. Therefore, claudication does not serve as a cue for venous ulcer development.

Choice C rationale

Cool and shiny skin, often accompanied by hair loss and thickened toenails, is indicative of chronic arterial insufficiency and poor localized perfusion. In venous disease, the skin is usually warm due to blood pooling and may be thick or leathery. Shiny skin suggests that the tissue is atrophic from a lack of oxygenated blood. Because venous ulcers occur in the context of high venous pressure and congestion, cool skin is not a characteristic finding.

Choice D rationale

Bronze-brown pigmentation, or hemosiderin staining, occurs in chronic venous insufficiency when high pressure causes red blood cells to leak into the surrounding tissue. As these cells break down, they release iron, which stains the skin. This discoloration is a significant cue that the patient has advanced venous disease and is at high risk for developing a venous ulcer. These ulcers typically form near the medial malleolus where venous hypertension is most severe.

A. Increased Heart Rate. B. Decreased Urine Output. C. Elevated Blood Urea Nitrogen (BUN). D. Decreased Hematocrit.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

A. Consistent with dehydration: In burn patients, an increased heart rate or tachycardia is a compensatory mechanism for hypovolemia. As fluid shifts from the intravascular space to the interstitial space due to increased capillary permeability, the circulating blood volume decreases. The heart compensates by increasing its rate to maintain cardiac output and tissue perfusion. This systemic response is a hallmark sign of the fluid volume deficit that occurs during the emergent phase of burn injuries.

B. Consistent with dehydration: Decreased urine output, or oliguria, occurs when the kidneys receive inadequate perfusion due to low intravascular volume and decreased cardiac output. In the context of a burn injury, extensive fluid loss through damaged skin and third-spacing leads to a drop in glomerular filtration rate. Monitoring urine output is a critical metric for assessing the adequacy of fluid resuscitation, with the goal being to reverse this sign of severe systemic dehydration.

C. Consistent with dehydration: An elevated blood urea nitrogen level reflects hemoconcentration and reduced renal blood flow. The normal range for blood urea nitrogen is 7 to 20 mg/dL. In a dehydrated burn patient, the lack of sufficient fluid causes the concentration of urea in the blood to rise as the kidneys struggle to excrete metabolic waste. This elevation indicates that the patient requires aggressive fluid replacement to restore osmotic balance and ensure proper renal clearance of toxins.

D. Consistent with fluid overload: A decreased hematocrit level often indicates hemodilution, which can occur during the state of fluid overload. While the hematocrit typically rises initially in burn patients due to plasma loss and hemoconcentration, a subsequent drop below the normal range of 42 to 52 percent for men or 37 to 47 percent for women may suggest excessive fluid administration. This occurs because the increased volume of administered fluids dilutes the existing red blood cell mass.

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A patient with full-thickness burns over 40 Which complication is vital for the nurse to anticipate and monitor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing a client with chronic venous insufficiency, which manifestation would provide a cue for the development of a venous ulcer?

Correct Answer is D

Explanation

A nurse is attending to a patient in the intensive care unit. For each patient finding below, indicate whether the finding is consistent with fluid overload or dehydration in burn patients.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

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