A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?

1. A

   Hypovolemia

2. B

   Laryngeal edema

3. C

   Hypernatremia

4. D

   Hyperkalemia

Appeared in: DHS Staff Nurse - 2018 (Shift-2nd)

Explanation

• Facial burns sustained in an explosion create a high index of suspicion for inhalation injury.
• Inhalation of hot gases and toxic fumes causes inflammation and swelling of the upper airway, known as laryngeal edema.
• According to the Airway, Breathing, Circulation (ABC) prioritization framework, maintaining a patent airway is the most immediate and critical priority.
• Airway obstruction from laryngeal edema can become fatal more quickly than other complications like hypovolemia or electrolyte imbalances.

Why Other Options Were Wrong

• Option A: Hypovolemia (burn shock) is a 'Circulation' problem. While it is a critical and expected complication of major burns, it is a lower priority than an immediate 'Airway' threat.
• Option C: This is not the expected electrolyte imbalance in the emergent phase. Due to fluid shifting out of the vascular space and into the interstitium, hyponatremia (low sodium) is more likely.
• Option D: Hyperkalemia results from the destruction of cells, which releases potassium. While it can cause life-threatening cardiac arrhythmias, it is not as immediately fatal as a complete airway obstruction.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Prioritization of care in the emergent phase of burn injuries in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Nurses must maintain a high index of suspicion for inhalation injury in any patient with facial burns, hoarseness, or soot around the nose/mouth.
• The primary nursing responsibility is continuous airway assessment and preparation for emergency intubation, as waiting can make the procedure impossible.
• What if? the burn was from a hot liquid spill on the legs, not a facial burn from an explosion? The priority would shift to 'Circulation,' focusing on fluid resuscitation to prevent hypovolemic shock and managing pain. Airway compromise would be a much lower risk.

How to Approach the Question

• First, identify the question as a priority question by noting the phrase 'most concerned'.
• Analyze the key clinical details: 'explosion' and 'burns to the face'. These are classic indicators for a high risk of inhalation injury.
• Apply the fundamental nursing prioritization principle: Airway, Breathing, Circulation (ABCs).
• Evaluate each option within the ABC framework: Laryngeal edema is an 'Airway' problem. Hypovolemia and Hyperkalemia are 'Circulation' problems. Hypernatremia is an incorrect electrolyte expectation.
• Conclude that the 'Airway' problem (laryngeal edema) is the highest and most immediate priority, making it the correct answer.

Concept Tested & Keywords

• Concept Tested: Prioritization of care in the emergent phase of burn injuries
• Stem keywords: explosion, burns to the face, 2 hours after
• Lead-in keywords: most concerned
• Clinical cues: Mechanism of injury (explosion) and location (face) are critical cues for inhalation injury risk.

Question ID

QktiCmVZda927PpwkhHvU6

Copy ID

Reference Book

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 pp. 697-699, 691-693

E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 60-62