The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.
The parent reports no signs of watery stools.
What nursing intervention should the nurse implement?

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

The patient vomiting at home for 3 days prior to surgery is crucial information that the PACU nurse should report. This could indicate a pre-existing condition or complication that needs to be addressed in the patient’s post-operative care plan.

Choice B rationale

While the patient refusing to take ice chips despite complaining of dry mouth is an important observation, it is not as critical as the patient’s pre-operative condition (vomiting for 3 days). The refusal of ice chips could be addressed through patient education and encouragement.

Choice C rationale

The presence of peripheral pulses and full range of motion in both legs is expected and normal in a post-operative patient, unless there were complications during surgery that could affect these observations. Therefore, this information, while important, is not as critical as the patient’s pre-operative condition.

Choice D rationale

The condition of the patient’s abdomen (soft, bowel sounds absent) and the absence of bleeding on the dressing are expected observations in a patient who has undergone an exploratory laparotomy. These observations, while important, do not provide additional critical information that the PACU nurse should report.