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.

Answer and Explanation

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.

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Correct Answer is ["B","D","E"]

Explanation

Choice A rationale

Not elevating the head of the bed increases the risk of aspiration of oropharyngeal secretions and gastric contents into the lungs. Gravity helps prevent reflux. Elevating the head of the bed to 30-45 degrees reduces the risk of ventilator-associated pneumonia by minimizing aspiration and promoting gastric emptying, which is a key preventative strategy.

Choice B rationale

Providing mouth care every 2-4 hours is critical for preventing ventilator-associated pneumonia. The oral cavity of intubated clients rapidly colonizes with pathogenic bacteria. Regular mouth care, including brushing teeth and cleansing oral mucosa with antiseptic solutions like chlorhexidine, significantly reduces bacterial load, thereby decreasing the risk of aspiration and subsequent pneumonia.

Choice C rationale

Refraining from suctioning the client would lead to the accumulation of pulmonary secretions, providing a fertile ground for bacterial growth and increasing the risk of ventilator-associated pneumonia. Suctioning is a necessary intervention to remove secretions, maintain airway patency, and reduce the bacterial burden in the lower respiratory tract, thus preventing infection.

Choice D rationale

Completing hand hygiene before touching the client is paramount for infection control. Microorganisms are commonly transmitted via healthcare workers' hands. Proper hand hygiene (washing with soap and water or using alcohol-based hand rub) before any client contact prevents the introduction of pathogens to the client, especially critical for immunocompromised or intubated individuals.

Choice E rationale

Performing hand hygiene before handling ventilatory tubing is essential to prevent the introduction of pathogens into the closed ventilator circuit. The tubing can serve as a conduit for microorganisms directly into the client's airways. Strict adherence to hand hygiene protocols before manipulating any part of the ventilator system minimizes the risk of contamination and subsequent infection.

A. Inform the health care provider that the client is ready to have the chest tube removed. B. Inform the health care provider that there is a probable leak in the drainage system. C. Encourage the client to breathe deeply so the water seal will stabilize. D. Document that the chest drainage system is functioning as intended.

Correct Answer is D

Explanation

Choice A rationale

Continuous bubbling in the water seal chamber indicates a persistent air leak within the chest drainage system, not readiness for removal. Air is actively escaping from the pleural space into the drainage system. Removal of the chest tube would be premature and potentially lead to pneumothorax recurrence or worsening as the air leak is still present.

Choice B rationale

While continuous bubbling can indicate a leak, intermittent bubbling synchronous with respirations, also known as tidaling, is a normal and expected finding. It reflects pressure changes within the pleural space during inspiration and expiration, demonstrating that the chest tube is patent and functioning properly to remove air and fluid.

Choice C rationale

Encouraging deep breathing can improve lung expansion and promote drainage but does not stabilize a water seal that is correctly functioning with intermittent bubbling. If there is a persistent air leak, deep breathing might temporarily increase the bubbling, but it does not resolve the underlying issue or alter normal physiological tidaling.

Choice D rationale

The observation of intermittent bubbling in the water seal chamber, synchronized with the client's respirations, is a normal and expected finding for a functioning chest drainage system. This phenomenon, known as tidaling, reflects the pressure changes within the pleural cavity during breathing, indicating that air is being effectively removed and the system is patent.

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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?

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A nurse is caring for a client on a ventilator. The nurse should include which of the following interventions in the plan of care to prevent ventilator associated pneumonia? (Select All that Apply)

Correct Answer is ["B","D","E"]

Explanation

A nurse is assessing a client with a chest tube and observes the water level in the water seal bubbling as the client breathes. How should the nurse best respond to this assessment finding?

Correct Answer is D

Explanation

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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?