A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect?

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.

Choice A reason: Serum sodium 140 mEq/L is a normal value and does not indicate an increase in osmolality. Osmolality is the concentration of dissolved particles in a fluid. Sodium is one of the main electrolytes that affect osmolality, but a normal sodium level does not necessarily mean a normal osmolality.

Choice B reason:

Serum potassium 4.0 mEq/L is also a normal value and does not indicate an increase in osmolality. Potassium is another electrolyte that affects osmolality, but it has a smaller effect than sodium. A normal potassium level does not necessarily mean a normal osmolality.

Choice C reason:

Serum glucose 90 mg/dL is also a normal value and does not indicate an increase in osmolality. Glucose is another substance that affects osmolality, but it has a smaller effect than electrolytes. A normal glucose level does not necessarily mean a normal osmolality.

Choice D reason:

Serum urea nitrogen 25 mg/dL is an elevated value and indicates an increase in osmolality. Urea nitrogen is a waste product of protein metabolism that is excreted by the kidneys. Urea nitrogen is one of the main substances that affect osmolality, along with sodium and glucose. An elevated urea nitrogen level means that the blood is more concentrated and has less water. This can be caused by dehydration, which is a common condition in clients who have dehydration. Dehydration leads to an increase in serum osmolality and activation of antidiuretic hormone (ADH), which results in urinary concentration. Therefore, choice D is the correct answer.