A nurse is assessing a client who has full-thickness burns. The nurse should identify that which of the following findings indicates the client's need for fluid resuscitation?
Explanation & Rationale
A. Engorged neck veins indicate fluid overload or increased central venous pressure, not hypovolemia. Fluid resuscitation is not indicated for this finding. B. Mild peripheral edema is not a reliable indicator of inadequate fluid volume in burn clients. Fluid shifts are common in burns, but mild edema alone does not signal the need for aggressive fluid replacement. C. Urine output is a key indicator of perfusion and fluid status in burn patients. The goal for fluid resuscitation is typically 30–50 mL/hr for adults. Urine output below 30 mL/hr suggests hypovolemia and inadequate renal perfusion, indicating the need for additional fluid resuscitation. D. Crackles suggest fluid overload or pulmonary edema, which may occur if fluid resuscitation is excessive. This finding does not indicate the need for more fluids; rather, it signals careful monitoring or possible reduction of fluid administration.