A patient who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation.
When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, what information should the nurse provide first?

Choice A rationale

The administration of crystalloid fluids in the first 24 hours following a burn incident promotes fluid resuscitation due to capillary leaking. In the aftermath of a burn, there is a disruption of the normal fluid balance in the body, leading to increased capillary permeability and fluid shifts. This can result in a condition known as burn shock, characterized by decreased blood volume and inadequate tissue perfusion. The administration of crystalloid fluids helps to restore intravascular volume, improve tissue perfusion, and prevent burn shock. It also minimizes burn wound conversion and reduces the incidences of post-burn renal failure, life-threatening electrolyte disturbances, and mortality.

Choice B rationale

While restoration of electrolyte balance is an important aspect of burn management, it is not the primary physiological response promoted by the administration of crystalloid fluids in the immediate aftermath of a burn. Electrolyte imbalances in burn patients are usually a result of the systemic inflammatory response, fluid shifts, and renal dysfunction that can occur after a burn. These imbalances are typically managed through careful monitoring and specific electrolyte replacement therapies, rather than through the initial administration of crystalloid fluids.

Choice C rationale

Replacement of insensible water loss is another important aspect of burn management, but it is not the primary physiological response promoted by the administration of crystalloid fluids in the immediate aftermath of a burn. Insensible water loss occurs through evaporation from the burn wound surface and can be significant in burn patients. However, this is typically managed through the maintenance of a humidified environment and specific fluid replacement strategies, rather than through the initial administration of crystalloid fluids.

Choice D rationale

Extension of plasma until blood is available is not the primary physiological response promoted by the administration of crystalloid fluids in the immediate aftermath of a burn. While blood products may be required in the management of severe burns, particularly if there is significant blood loss or hemodynamic instability, the initial focus of fluid resuscitation in burn patients is on the administration of crystalloid solutions to restore intravascular volume and improve tissue perfusion.

Choice A rationale

Reassuring the client that the nurse will return after all vital signs are taken might not be the most appropriate action in this situation. The client is critically ill and might need immediate emotional support.

Choice B rationale

Pulling up a chair and sitting beside the client’s bed is the most appropriate action. This action shows empathy and provides emotional support, which is crucial in the care of critically ill patients.

Choice C rationale

Allowing the client to hold the nurse’s hand until the vital signs can be completed might provide some comfort to the client. However, it might not be feasible if the nurse needs to use both hands to complete the vital signs.

Choice D rationale

Telling the client that he must release the nurse’s hand might not be the most appropriate action. It might come across as dismissive and could potentially upset the client.