Fluid Pressures/Movements (Starling's Law)
Fluid Pressures/Movements (Starling's Law) ( 5 Questions)
A nurse is caring for a client who has a severe burn injury and is receiving intravenous fluid replacement therapy. Which of the following actions should the nurse take to monitor fluid shifts in this client? (Select all that apply.)
Measure intake and output. This is a correct action because it helps to monitor the fluid balance and renal function of the client who has a severe burn injury and is receiving intravenous fluid replacement therapy. Fluid shifts can cause hypovolemia, dehydration, electrolyte imbalances, and renal failure in burn patients. Measuring intake and output can help to detect these complications and adjust the fluid therapy accordingly.
Assess skin turgor. This is an incorrect action because it is not a reliable indicator of fluid status in burn patients. Burn injuries can damage the skin and alter its elasticity, making skin turgor assessment inaccurate. Other methods of assessing hydration, such as mucous membranes, capillary refill, and urine specific gravity, are more appropriate for burn patients.
Check blood pressure. This is a correct action because it helps to monitor the hemodynamic status and perfusion of the client who has a severe burn injury and is receiving intravenous fluid replacement therapy. Fluid shifts can cause hypotension, shock, and organ damage in burn patients. Checking blood pressure can help to detect these complications and adjust the fluid therapy accordingly.
Weigh the client daily. This is a correct action because it helps to monitor the fluid balance and nutritional status of the client who has a severe burn injury and is receiving intravenous fluid replacement therapy. Fluid shifts can cause weight changes, edema, and protein loss in burn patients. Weighing the client daily can help to detect these complications and adjust the fluid therapy accordingly.
Monitor serum albumin levels. This is a correct action because it helps to monitor the fluid balance and protein status of the client who has a severe burn injury and is receiving intravenous fluid replacement therapy. Fluid shifts can cause hypoalbuminemia, which can lead to edema, decreased oncotic pressure, and impaired wound healing in burn patients. Monitoring serum albumin levels can help to detect this complication and adjust the fluid therapy accordingly.
Choice A reason:
Measure intake and output. This is a correct action because it helps to monitor the fluid balance and renal function of the client who has a severe burn injury and is receiving intravenous fluid replacement therapy. Fluid shifts can cause hypovolemia, dehydration, electrolyte imbalances, and renal failure in burn patients. Measuring intake and output can help to detect these complications and adjust the fluid therapy accordingly.
Choice B reason:
Assess skin turgor. This is an incorrect action because it is not a reliable indicator of fluid status in burn patients. Burn injuries can damage the skin and alter its elasticity, making skin turgor assessment inaccurate. Other methods of assessing hydration, such as mucous membranes, capillary refill, and urine specific gravity, are more appropriate for burn patients.
Choice C reason:
Check blood pressure. This is a correct action because it helps to monitor the hemodynamic status and perfusion of the client who has a severe burn injury and is receiving intravenous fluid replacement therapy. Fluid shifts can cause hypotension, shock, and organ damage in burn patients. Checking blood pressure can help to detect these complications and adjust the fluid therapy accordingly.
Choice D reason:
Weigh the client daily. This is a correct action because it helps to monitor the fluid balance and nutritional status of the client who has a severe burn injury and is receiving intravenous fluid replacement therapy. Fluid shifts can cause weight changes, edema, and protein loss in burn patients. Weighing the client daily can help to detect these complications and adjust the fluid therapy accordingly.
Choice E reason:
Monitor serum albumin levels. This is a correct action because it helps to monitor the fluid balance and protein status of the client who has a severe burn injury and is receiving intravenous fluid replacement therapy. Fluid shifts can cause hypoalbuminemia, which can lead to edema, decreased oncotic pressure, and impaired wound healing in burn patients. Monitoring serum albumin levels can help to detect this complication and adjust the fluid therapy accordingly.