The nurse is caring for a client in the intensive care unit who suffered partial-thickness burns to 36% of the body. During the first 24 hours, the nurse would anticipate which of the following assessments?

Question

The nurse is caring for a client in the intensive care unit who suffered partial-thickness burns to 36% of the body.  During the first 24 hours, the nurse would anticipate which of the following assessments?

Quizplus · Accepted Answer

11ecbb05_c9f9_4585_b433_c9606fff2768_MD0009_00 Burn injuries cause tissue damage that leads to increased vascular permeability and fluid shifts (eg, second and third spacing). In the emergent phase after a burn (first 24-72 hours), fluid, proteins, and intravascular components leak into the surrounding interstitium, causing decreased intravascular oncotic pressure and decreased intravascular volume, and resulting in fluid shifts and hypovolemia. Potassium, the predominant intracellular cation, is released when cellular damage occurs, resulting in hyperkalemia (potassium >5.0 mEq [5.0 mmol/L]). Clients with hyperkalemia experience muscle weakness, ECG changes (tall, peaked T waves, shortened QT interval), and cardiac arrhythmias (Option D). (Option A) Hematocrit and hemoglobin values will be elevated due to hypovolemia (hemoconcentration). (Option B) The sympathetic nervous system is activated in response to a burn, causing decreased peristalsis. Nausea, vomiting, gastric distension, and paralytic ileus may occur. (Option C) Sodium is the most abundant extracellular cation. Hyponatremia (sodium <135 mEq/L [135 mmol/L]) occurs as sodium is lost via fluid shifts and insensible losses. Educational objective: Burn injuries cause cellular destruction, capillary leaking, and fluid shifts. Fluids are lost during the emergent phase (first 24-72 hours), resulting in hypovolemia and hyponatremia. The blood becomes more viscous and increased hematocrit and hemoglobin values result. Cellular damage releases potassium, which causes hyperkalemia.

The Nurse Is Caring for a Client in the Intensive