A nurse in the emergency room is performing an assessment on a burn victim. She notes his face is a cherry-red color and suspects which of the following problems?

Choice A reason: While atrial fibrillation, bilateral basilar crackles, and a blood pressure of 110/62 indicate important findings in a client with heart failure, they are not immediately life-threatening compared to the symptoms in choice d. Bilateral crackles suggest fluid overload and pulmonary congestion, which require attention, but the priority should be on more critical signs of decreased perfusion.

Choice B reason: Weight gain of 1 kg in 3 days and mild dyspnea with exercise are signs of fluid retention and worsening heart failure. However, they are not as urgent as the symptoms of confusion and low urine output, which suggest severe hypoperfusion and potential organ failure.

Choice C reason: A SpO2 of 92% on 2L nasal cannula, respirations of 20/min, and 1+ edema of the lower extremities indicate mild hypoxemia and fluid overload. Although these findings are important and need management, they are not as critical as the symptoms in choice d, which suggest severe hypoperfusion and a potential emergency.

Choice D reason: Confusion, urine output of 15 mL over the last 2 hours, and orthopnea are the most concerning findings. Confusion indicates decreased cerebral perfusion, which is a sign of severe heart failure and possibly impending cardiogenic shock. Low urine output (oliguria) suggests poor renal perfusion, indicating that the kidneys are not receiving enough blood flow. Orthopnea (difficulty breathing while lying down) is a classic symptom of severe heart failure and pulmonary congestion. These symptoms suggest that the client is in a critical condition that requires immediate intervention to improve perfusion and prevent further deterioration.

Choice A reason: An increased albumin level, while noteworthy, is not typically an urgent finding to communicate immediately following paracentesis. Albumin levels can fluctuate for various reasons, and elevated levels do not generally indicate a critical issue requiring immediate intervention.

Choice B reason: A normal platelet count is a good sign, indicating that the patient has an adequate number of platelets for blood clotting and wound healing. This finding does not indicate an urgent need to notify the healthcare provider immediately.

Choice C reason: A 2-cm area of serous drainage on the dressing is relatively small and expected after a procedure like paracentesis. It suggests that the site is draining some fluid, which is normal post-procedure. While it should be monitored, it does not necessitate urgent communication unless it worsens or there are signs of infection.

Choice D reason: A heart rate of 122 beats/min is tachycardia and can indicate several potential complications, including hypovolemia (low blood volume) due to the large fluid removal, infection, or other stressors on the patient's body. This finding is the most critical to communicate to the healthcare provider promptly as it may require immediate intervention to address the underlying cause and stabilize the patient.