The 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 abnormal laboratory result?
Metabolic alkalosis.
Hypernatremia.
Hyperkalemia.
Decreasing hematocrit.
The Correct Answer is C
Choice A rationale
Metabolic alkalosis is characterized by an elevated blood pH and bicarbonate levels. In the emergent phase of burn shock, extensive tissue damage releases cellular contents, including acids, and the body's compensatory mechanisms typically involve bicarbonate buffering. However, the primary physiological derangement is often metabolic acidosis due to hypoperfusion and anaerobic metabolism, not alkalosis. Normal arterial pH is 7.35-7.45.
Choice B rationale
Hypernatremia, an elevated serum sodium concentration (normal range 135-145 mEq/L), is not typically seen in the initial phase of burn shock. Instead, there is often significant fluid loss from the intravascular space into the interstitial space due to increased capillary permeability. This fluid shift usually leads to hyponatremia as sodium is diluted by the administration of hypotonic intravenous fluids.
Choice C rationale
Hyperkalemia, an elevated serum potassium concentration (normal range 3.5-5.0 mEq/L), is a common and critical abnormality in the emergent phase of thermal burns. Extensive cellular destruction from the burn injury causes the release of intracellular potassium into the extracellular fluid. This can lead to life-threatening cardiac dysrhythmias due to altered myocardial excitability.
Choice D rationale
A decreasing hematocrit, the percentage of red blood cells in the blood (normal range for males 40-54%, females 36-48%), is not typical in the initial emergent phase of burn shock. While fluid shifts out of the vasculature occur, leading to hypovolemia, the loss is primarily plasma. This results in hemoconcentration, increasing the hematocrit due to relative red blood cell elevation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Human immunodeficiency virus (HIV) is transmitted through specific body fluids, including blood, semen, pre-ejaculatory fluid, rectal fluids, vaginal fluids, and breast milk. Standard precautions are universally applied infection control practices designed to prevent transmission of infectious agents from recognized or unrecognized sources in healthcare settings. This includes hand hygiene and the use of personal protective equipment.
Choice B rationale
Respiratory isolation, such as airborne or droplet precautions, is implemented for diseases spread via airborne particles or respiratory droplets. HIV is not transmitted through the airborne or droplet route; therefore, respiratory isolation is an unnecessary and inappropriate measure for routine care of an HIV-positive individual.
Choice C rationale
Contact isolation is employed for infections spread by direct or indirect contact with the client or their environment, such as methicillin-resistant Staphylococcus aureus. HIV is not primarily transmitted through casual contact or fomites; thus, contact isolation is not indicated for the daily care of an HIV-positive individual.
Choice D rationale
An isolation gown is a component of personal protective equipment used in contact or droplet isolation to prevent contamination of clothing from splashes or sprays of infectious materials. Since HIV transmission requires direct contact with specific body fluids, a gown is not routinely necessary for providing care unless exposure to such fluids is anticipated. .
Correct Answer is A
Explanation
Choice A rationale
A sentinel event is an unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a client, not related to the natural course of the client's illness. A hemolytic transfusion reaction with an incompatible blood type, leading to client recovery, perfectly fits this definition due to its severity and preventability.
Choice B rationale
A never event is a medical error that is clearly identifiable, preventable, and serious in its consequences for the client. While a hemolytic transfusion reaction is preventable, the term "never event" specifically refers to a list of events identified by organizations like the National Quality Forum that should never occur. While closely related, "sentinel event" emphasizes the severe outcome.
Choice C rationale
A minor injury refers to an injury that is not severe or life-threatening and does not result in significant long-term harm or disability. A hemolytic transfusion reaction is a severe and potentially life-threatening immunological response to incompatible blood, making "minor injury" an inaccurate description of the event's severity and implications.
Choice D rationale
Root Cause Analysis (RCA) is a systematic process for identifying the underlying causes of problems or incidents in a healthcare setting. While an RCA would be conducted following a sentinel event like a hemolytic transfusion reaction to prevent recurrence, RCA itself is a process, not a type of safety event. The event itself is the sentinel event.
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