The nurse reviews the client's test results.

Exhibits

Complete the following sentence by using the list of options.

The nurse should wear

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A. Weight loss: Fluid overload is characterized by excessive fluid retention rather than loss. Weight gain is a more common finding due to fluid accumulation in tissues. Weight loss would be associated with dehydration, malnutrition, or inadequate caloric intake rather than fluid overload.
B. Decreased blood pressure: Fluid overload typically leads to increased blood pressure due to excess circulating volume. Decreased blood pressure is more commonly seen in dehydration or conditions that result in significant fluid loss, such as hemorrhage or severe diarrhea.
C. Decreased skin turgor: Poor skin turgor is a sign of dehydration rather than fluid overload. In fluid overload, clients may exhibit edema, moist skin, and increased vascular volume instead of signs of dehydration.
D. Crackles heard in the lungs: Crackles in the lungs indicate pulmonary congestion due to excess fluid accumulation, which can occur with fluid overload. Increased intravascular volume leads to leakage of fluid into the alveoli, causing difficulty breathing, shortness of breath, and pulmonary edema in severe cases.

A. Use aseptic technique during wound care for the client. While using aseptic technique is essential for preventing infection during wound care, it is not the immediate priority upon admission. The nurse must first assess the client's airway and oxygenation status.
B. Obtain the client's oxygen saturation levels. Obtaining the client's oxygen saturation levels is the priority action. Clients with burns, especially those affecting the upper torso, may have compromised airway patency or inhalation injury. Assessing oxygen saturation is crucial for determining the need for supplemental oxygen or further airway interventions.
C. Check the client's WBC count. Checking the client's white blood cell (WBC) count is important for evaluating potential infection and overall health status, but it is not an immediate priority in the acute phase of burn management. The nurse should focus first on airway and respiratory assessment.
D. Regulate IV fluids to maintain the client's urinary output. Regulating IV fluids to maintain urinary output is an important action in managing burn clients, as fluid resuscitation is critical. However, it should be done after ensuring the client's airway and oxygenation are stable, as inadequate oxygenation could complicate fluid resuscitation efforts.