NursingPlex
    Sign In
    RN Adult Medical Surgical 2023 Proctored Exam

    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. Urine output 25 mL/hr: Low urine output indicates inadequate renal perfusion, which can result from fluid loss due to burn injuries. In clients with full-thickness burns, maintaining adequate urine output is a key indicator that fluid resuscitation is needed to restore circulating volume and prevent shock. B. Engorged neck veins: Engorged neck veins suggest fluid overload or increased central venous pressure rather than hypovolemia. This finding would not indicate the need for fluid resuscitation in a burn patient. C. 1+ pitting peripheral edema: Mild peripheral edema may occur with fluid shifts but does not alone indicate the need for aggressive fluid resuscitation. It is less critical than indicators of organ perfusion such as urine output. D. Bilateral lung crackles: Lung crackles indicate fluid accumulation in the lungs, possibly from pulmonary edema, and would suggest caution with fluid administration rather than the need for additional fluids.

    🔒 Submit your answer to reveal