The nurse is caring for a patient recently admitted with a 50% total body surface area burn. Upon evaluating laboratory results, which result requires an immediate nursing intervention?

Serum potassium 6.5 mEq/L

Hematocrit 52%

Serum sodium 146 mEq/L

Urine specific gravity 1.005

Answer and Explanation

The Correct Answer is A

A. Serum potassium 6.5 mEq/L: Hyperkalemia is a life-threatening electrolyte imbalance commonly seen in burn patients due to cellular destruction and release of intracellular potassium. A potassium level of 6.5 mEq/L can precipitate dangerous cardiac dysrhythmias, including ventricular fibrillation or asystole. Immediate nursing interventions include cardiac monitoring, notifying the healthcare provider, and preparing for treatments.

B. Hematocrit 52%: Elevated hematocrit reflects hemoconcentration, which is common in burn patients due to fluid shifts and plasma loss. While it indicates dehydration and ongoing fluid resuscitation needs, it is not immediately life-threatening and can be addressed with continued monitoring and IV fluids.

C. Serum sodium 146 mEq/L: A sodium level slightly above normal indicates mild hypernatremia, which can occur due to fluid shifts and inadequate free water replacement. Although it requires monitoring and adjustment of fluid therapy, it does not pose the same immediate risk as hyperkalemia.

D. Urine specific gravity 1.005: This value suggests dilute urine, which may indicate adequate hydration or early renal impairment. While it warrants monitoring in the context of burn resuscitation, it does not require urgent intervention compared with a dangerously high potassium level.

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Correct Answer is ["A","C","F"]

Explanation

Rationale for correct choices

• Compartment syndrome: The client has multiple severe fractures with edema in the bilateral lower extremities. Swelling within the confined fascial compartments increases pressure, compromising circulation and tissue perfusion. Without prompt recognition and intervention, ischemia can lead to permanent muscle and nerve damage, making compartment syndrome a high-risk complication in this scenario.

• Fat embolism: The client has long bone fractures, including the femur and tibias, which are major sources of fat emboli entering the bloodstream. Fat embolism syndrome can develop 24–72 hours post-injury, presenting with respiratory distress, petechial rash, and neurological changes. Early recognition is essential to provide supportive care and prevent severe hypoxia or multisystem complications.

• Neurogenic shock: The MRI shows complete severance of the spinal cord at T8. Injury at this level can disrupt sympathetic nervous system pathways, causing hypotension, bradycardia, and warm, flushed skin below the injury. Neurogenic shock is a life-threatening complication following high spinal cord injuries and requires immediate hemodynamic monitoring and management.

Rationale for incorrect choices

• Hypoglycemia: There is no indication that the client has diabetes, endocrine disorders, or prolonged fasting that would place him at immediate risk for hypoglycemia. While blood glucose should be monitored in critically ill patients, it is not a high-risk complication specific to trauma or spinal cord injury in this case.

• Hypovolemic shock: Although the client has multiple fractures, the FAST exam was negative, and initial vital signs show only mild tachycardia with stable blood pressure. There is no evidence of massive blood loss at this time. While hypovolemic shock remains a general concern in trauma, the immediate high-risk complications are more directly related to neurovascular compromise and spinal injury.

• Infection: Infection is a potential concern due to open fractures, but it is not an immediate high-risk complication in the acute trauma phase. Prophylactic antibiotics and sterile wound care reduce early risk. The client’s urgent threats are more related to tissue perfusion, embolic events, and spinal cord–mediated shock.

A. Sitting in the tripod position B. 02 saturation of 91% C. Respiratory rate has decreased from 30 to 10 breaths/min D. Bilateral lung crackles

Correct Answer is C

Explanation

A. Sitting in the tripod position: Tripod positioning is a common compensatory mechanism in patients with COPD to maximize diaphragmatic expansion and ease breathing. While it indicates respiratory distress, it is an expected adaptive behavior and not immediately life-threatening.

B. O₂ saturation of 91%: An oxygen saturation of 91% is slightly below normal and should be monitored. In COPD patients, target saturations are often 88–92%, so this finding alone may not require urgent intervention if the patient is otherwise stable.

C. Respiratory rate has decreased from 30 to 10 breaths/min: A sudden drop in respiratory rate in a patient previously tachypneic is highly concerning, as it suggests impending respiratory failure or fatigue of the respiratory muscles. This change indicates inadequate ventilation and CO₂ retention, requiring immediate notification to the healthcare provider for urgent intervention.

D. Bilateral lung crackles: Crackles may indicate fluid overload, infection, or pulmonary edema, which are important to monitor and treat. However, in acute respiratory distress, a decreasing respiratory rate represents a more immediate threat to oxygenation and ventilation, making it the highest priority to report.

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The nurse is caring for a patient recently admitted with a 50% total body surface area burn. Upon evaluating laboratory results, which result requires an immediate nursing intervention?

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Naxlex Comprehensive Predictor Exams

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