Nokea
A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what?
- A. Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
- B. Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis
- C. Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis
- D. Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis
Correct Answer: A
Rationale: In the emergent phase, cell damage releases potassium (hyperkalemia), sodium is lost to edema (hyponatremia), hemoconcentration increases hematocrit, and tissue hypoxia causes metabolic acidosis. Other combinations do not align with burn pathophysiology.
You may also like to solve these questions
A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment?
- A. 4 to 6 hours a day for 6 months
- B. During waking hours for 2 to 3 months after the injury
- C. Continuously
- D. At night while sleeping for a year after the injury
Correct Answer: C
Rationale: Elastic pressure garments should be worn continuously (23 hours/day) to minimize scarring and contractures, typically for months until scars mature.
An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn?
- A. The causative agent
- B. The patients preinjury health status
- C. The patients prognosis for recovery
- D. The circumstances of the accident
Correct Answer: A
Rationale: Burn depth is determined by factors like the causative agent (e.g., scalding liquid), temperature, contact duration, and skin thickness. Preinjury health, prognosis, and accident circumstances are not direct determinants.
An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury?
- A. The length of time since the burn
- B. The location of burned skin surfaces
- C. The source of the burn
- D. The total body surface area (TBSA) affected by the burn
Correct Answer: D
Rationale: TBSA is the primary determinant of systemic response, as larger burns cause greater fluid loss, metabolic demand, and organ stress. Time, location, and source are secondary factors.
A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, I cant wait to have surgery to reconstruct my face so I look normal again. What would be the nurses best response?
- A. Thats something that you and your doctor will likely talk about after your scars mature.
- B. That is something for you to talk to your doctor about because its not a nursing responsibility.
- C. I know this is really important to you, but you have to realize that no one can make you look like you used to.
- D. Unfortunately, its likely that you will have most of these scars for the rest of your life.
Correct Answer: A
Rationale: Reconstructive surgery is considered after scars mature, typically within 1-2 years, making this an appropriate, hopeful response. Other options dismiss the patient's concern or lack empathy.
A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patients legs distal to the wound site, the nurse should be cognizant of the risk of what complication?
- A. Ischemia
- B. Referred pain
- C. Cellulitis
- D. Venous thromboembolism (VTE)
Correct Answer: A
Rationale: Circumferential burns can cause edema, compressing blood vessels and leading to distal ischemia, similar to compartment syndrome. Referred pain, cellulitis, or VTE are less immediate concerns.