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.)

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:

Sodium attracts water and increases the fluid volume in your blood vessels. This is the correct answer because sodium is an electrolyte that helps regulate the balance of fluids in the body. When there is too much sodium in the blood, it draws water from the cells and tissues into the blood vessels, increasing the blood volume and pressure. This puts extra strain on the heart and can worsen heart failure symptoms.

Choice B reason:

Sodium causes water to move out of your cells and into your urine. This is incorrect because sodium does not cause water to move out of the cells and into the urine. In fact, sodium can cause water retention by stimulating the release of antidiuretic hormone (ADH), which reduces urine output and increases blood volume.

Choice C reason:

Sodium stimulates your kidneys to retain water and decrease urine output. This is incorrect because sodium does not directly stimulate the kidneys to retain water and decrease urine output. However, sodium can indirectly affect the kidney function by increasing the blood volume and pressure, which can damage the kidney cells and impair their ability to filter waste and excess fluid from the body.

Choice D reason:

Sodium interferes with the action of your heart medications. This is incorrect because sodium does not interfere with the action of your heart medications. However, some heart medications, such as diuretics, can cause sodium loss in the urine, which can lead to low blood sodium levels (hyponatremia) This can cause symptoms such as confusion, weakness, nausea, and muscle cramps. Therefore, it is important to monitor your sodium intake and blood levels while taking heart medications.