A client who was rescued from a house fire is admitted to the burn unit with deep dermal, partial thickness (second degree) burns over approximately one-third of the back and upper thighs. The
nurse begins administration of prescribed crystalloid fluids for the first 24-hours following the burn incident. Which physiological response is promoted by the administration of the fluids?

Rationale

A. Blood cultures are typically obtained to identify the causative organism of the liver abscess and to monitor the effectiveness of antimicrobial therapy. While repeat blood cultures may be considered if there is concern for ongoing infection or antimicrobial resistance, they may not be the immediate priority in the context of new-onset jaundice.

B. Jaundice indicates possible liver dysfunction, which can occur due to various reasons including progression of the liver abscess, obstruction of the bile ducts, or drug-induced liver injury from antimicrobial therapy. Evaluating liver function tests (such as serum bilirubin, liver enzymes) is essential to assess the extent of liver damage and guide further management.

C. Increasing protein intake is generally not indicated as the immediate response to jaundice. While adequate nutrition is important, specific dietary adjustments should be based on comprehensive assessment findings and medical recommendations.

D. Emergency transport to an inpatient facility may be necessary if the client shows signs of severe complications such as hemodynamic instability, worsening symptoms, or acute liver failure. However, this decision should be based on a thorough assessment of the client's condition and the availability of resources at the community clinic.

Rationale

A. This is generally a good practice for clients who may have difficulty ambulating to the bathroom due to their condition. It promotes safety and reduces the risk of falls, especially during episodes of dyspnea.

B. A supine position can increase venous return to the heart and exacerbate symptoms of heart failure by increasing preload. This can lead to increased pulmonary congestion and respiratory distress. Therefore, this observation requires immediate intervention.

C. Providing a low sodium diet aligns with managing heart failure by reducing fluid retention and workload on the heart. This observation does not require immediate intervention unless there are specific dietary restrictions or concerns.

D. In heart failure, fluid restriction is often necessary to prevent fluid overload and exacerbation of symptoms. Having a full pitcher of water accessible to the client could lead to excessive fluid intake, which is concerning and requires immediate intervention.

E. A saline lock allows access for intravenous medications or fluids if needed. Its presence does not necessarily indicate a need for immediate intervention unless it is not functioning properly or if there are signs of infection or infiltration.