During the emergent phase of burn care, which nursing action will be most useful in determining if a patient is receiving adequate fluid resuscitation?

A. Hyperkalemia: Acute kidney injury (AKI) impairs renal excretion of potassium, leading to dangerous elevations in serum potassium. IV regular insulin with glucose shifts potassium into cells temporarily, lowering serum levels. Sodium bicarbonate can also drive potassium intracellularly by correcting acidosis, and IV calcium gluconate stabilizes cardiac membranes to reduce the risk of arrhythmias. These interventions target the life-threatening hyperkalemia.

B. Hypocalcemia: Hypocalcemia is a potential complication of AKI due to phosphate retention, but calcium gluconate alone treats the cardiac effects, not the underlying cause. Insulin, glucose, and sodium bicarbonate are not used to correct low calcium levels.

C. Hyperglycemia: Hyperglycemia is not a typical complication of AKI; IV insulin in this context is used for potassium management, not glucose control. The glucose administered alongside insulin prevents hypoglycemia during potassium shifting.

D. Hypoglycemia: Hypoglycemia is not commonly associated with AKI. The glucose given is preventive during insulin administration to shift potassium into cells, rather than treatment of existing low blood sugar.

A. Administer IV morphine: Restlessness and stridor in a patient with facial burns strongly suggest impending airway obstruction due to edema or inhalation injury. Administering morphine may further depress respiratory drive and mask worsening airway compromise. Pain control is important but does not address the immediate threat of airway occlusion.

B. Call for stat airway support: Stridor indicates upper airway narrowing, and in the setting of facial burns, progressive edema can rapidly lead to complete airway obstruction. Early airway intervention, including preparation for endotracheal intubation, is critical before swelling makes intubation difficult or impossible. Securing the airway is the highest priority in burn management

C. Elevate the HOB: Elevating the head of the bed may help reduce facial edema and promote ventilation, but it is a supportive measure rather than a definitive intervention. It does not prevent rapid airway closure caused by burn-related swelling. Immediate airway management takes precedence.

D. Obtain ABG: Arterial blood gas analysis provides information about oxygenation and ventilation but does not treat airway compromise. Waiting for ABG results could delay lifesaving airway intervention. Clinical signs such as stridor and restlessness warrant immediate action to secure the airway.