The nurse in the burn unit provides discharge instructions for a client who received a skin graft due to deep partial-thickness burns from a work accident at a chemical plant.
Which instruction should the nurse prioritize?

Delegation to unlicensed assistive personnel requires understanding the scope of practice regarding stable vs unstable clients. Knowledge of the nursing process, specifically the difference between assessment or teaching and implementation of standard safety tasks, is required for this decision.

Choice A rationale

Teaching is a core nursing responsibility that requires specialized knowledge and clinical judgment. UAPs cannot perform initial or formal education on therapeutic techniques like the chin tuck, as they are not trained to evaluate the effectiveness of teaching.

Choice B rationale

Positioning a client upright and providing supervision during meals are standard safety tasks within the UAP scope of practice. This intervention supports safe swallowing while allowing the UAP to assist the client in a stable, repetitive manner.

Choice C rationale

Evaluation is the final step of the nursing process and must be performed by a registered nurse. Identifying signs of aspiration requires clinical observation and interpretation of physiological data, which exceeds the training and role of the UAP.

Choice D rationale

Assessment of swallowing ability is a complex task that requires clinical expertise and judgment. The registered nurse must perform the initial and ongoing assessments to determine the client's risk level and the safety of the current feeding plan..

Managing hyperkalemia and burn injuries necessitates rapid assessment and specialized intervention. Understanding the electrophysiology of the heart and the mechanical pressure exerted by burned skin allows nurses to intervene effectively to stabilize cardiac rhythms and maintain peripheral pulses and perfusion.

Choice A rationale

Potassium supplements would exacerbate hyperkalemia, further increasing the extracellular potassium concentration. This would worsen cardiac membrane depolarization, potentially leading to fatal ventricular arrhythmias or asystole. Normal serum potassium levels range from 3.5 to 5.0 mEq/L.

Choice B rationale

Continuous cardiac monitoring is vital because hyperkalemia alters the myocardial resting membrane potential. This can lead to peaked T waves, widened QRS complexes, and cardiac arrest. Constant surveillance allows for immediate detection of life-threatening electrical changes.

Choice C rationale

Calcium gluconate is administered to stabilize the cardiac cell membrane. It does not lower potassium levels but antagonizes the cardiotoxic effects of hyperkalemia by increasing the threshold potential, thereby reducing the risk of lethal arrhythmias.

Choice D rationale

Hemodialysis is the most definitive and rapid method to remove excess potassium from the blood. It is indicated in severe, symptomatic hyperkalemia when medical therapies are insufficient to stabilize the patient or clear the electrolyte.

Choice E rationale

While diuretics like furosemide can increase potassium excretion, they are often too slow for emergency stabilization in severe hyperkalemia with arrhythmias. They require adequate renal perfusion and function, making them a secondary rather than primary intervention.