Nokea
The nurse is caring for a client with a major thermal burn. Which initial laboratory abnormalities does the nurse anticipate in response to the burn? Select all that apply.
- A. Hemodilution
- B. Hyperkalemia
- C. Metabolic Acidosis
- D. Hyperglycemia
- E. Hemoconcentration
Correct Answer: B, C, D, E
Rationale: Burns cause hyperkalemia (cell destruction), metabolic acidosis (tissue hypoxia), hyperglycemia (stress response), and hemoconcentration (fluid loss).
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The nurse cares for a 29-year-old male in the emergency department (ED)
Item 1 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
Which two (2) assessment findings is the nurse most concerned with?
- A. h
- B. Extent of injury
- C. Oral temperature
- D. Type of burns
- E. Sensation in the right arm
Correct Answer: B, E
Rationale: The extent of injury (full- and partial-thickness burns) and loss of sensation in the right arm (indicating possible nerve damage) are critical concerns requiring immediate attention.
The nurse is caring for a client with several severe pressure ulcers. Which laboratory result requires the nurse to intervene?
- A. Serum albumin level of 2.5 g/dL [3.5-5 g/dL]
- B. Serum potassium level of 4 mEq/L (mmol/L) [3.5 and 5.0 mEq/L (mmol/L)]
- C. Serum sodium level of 140 mEq/L (mmol/L) [135-145 mEq/L (mmol/L)]
- D. White blood cell count of 9,000 cells/uL (9x10%) [4,500-11,000 cells/uL, 3.5-10.5 × 10°/L]
Correct Answer: A
Rationale: A low serum albumin level (2.5 g/dL) indicates malnutrition, which impairs wound healing and requires intervention. Other lab values are within normal ranges.
The nurse is caring for a client who sustained an electrical burn. Which priority action should the nurse take?
- A. Obtain an electrocardiogram (ECG)
- B. Obtain an order for an arterial blood gas (ABG)
- C. Perform wound care
- D. Initiate supplemental oxygen
Correct Answer: A
Rationale: Electrical burns can cause cardiac dysrhythmias, so obtaining an ECG is the priority to assess heart rhythm.
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 6 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
The nurse assesses the urine output and determines whether the client is meeting the treatment goal when it reaches
- A. 0.10 mL/kg/hr
- B. 0.25 mL/kg/hr
- C. 0.4 mL/kg/hr
- D. 0.5 mL/kg/hr
Correct Answer: D
Rationale: A urine output of 0.5 mL/kg/hr indicates adequate renal perfusion and effective fluid resuscitation in burn patients.
A nurse is assigned to care for a client who reportedly has no special skincare needs. However, upon assessment, the nurse observes reddened areas over bony prominences. What action should the nurse take?
- A. Document the finding and continue with routine care
- B. Apply a topical antibiotic ointment to the affected areas
- C. Conduct and document an emergency assessment
- D. Perform and document a focused assessment of skin integrity
Correct Answer: D
Rationale: Reddened areas over bony prominences suggest early pressure ulcers, requiring a focused skin integrity assessment to guide interventions.