A nurse is caring for a client who was brought to the emergency department (ED) by EMS after diving into a lake and losing consciousness. The client was intubated in the field by the paramedics. A CT of the head and neck revealed a spinal cord injury at the level of C3-4. What is the priority nursing action?

Choice A Reason:
0.9% sodium chloride is an isotonic crystalloid solution often used for fluid resuscitation. However, it is not the preferred choice for burn patients because it lacks the necessary electrolytes to replace those lost through burn injuries. While it can be used if Lactated Ringer's is unavailable, it does not provide the same balanced electrolyte composition.

Choice B Reason:
Lactated Ringer's is the preferred fluid for initial resuscitation in burn patients. It is an isotonic crystalloid solution that closely mimics the body's plasma, providing essential electrolytes such as sodium, potassium, calcium, and lactate. The lactate in the solution acts as a buffer, helping to correct metabolic acidosis, which is common in burn patients. The Parkland formula, widely used for calculating fluid needs in burn patients, specifically recommends Lactated Ringer's for the first 24 hours.

Choice C Reason:
Dextrose 5% in water is a hypotonic solution that provides free water and calories but lacks electrolytes. It is not suitable for initial fluid resuscitation in burn patients because it does not address the electrolyte imbalances and large fluid shifts that occur after a burn injury. Using this solution could lead to further complications such as hyponatremia.

Choice D Reason:
Dextrose 5% in 0.9% sodium chloride is a hypertonic solution that provides both glucose and electrolytes. However, it is not typically used for initial burn resuscitation because the high glucose content can lead to hyperglycemia, which is detrimental to burn patients. Additionally, the solution's osmolarity can exacerbate fluid shifts and worsen edema.

Choice A Reason:
Urine output is one of the most reliable indicators of adequate fluid resuscitation in burn patients. The goal is to maintain a urine output of 0.5 to 1 mL/kg/hour in adults³. This parameter is crucial because it directly reflects renal perfusion and, by extension, overall circulatory volume status. When fluid resuscitation is adequate, the kidneys receive enough blood flow to produce urine at this rate, indicating that the body's tissues are being adequately perfused. Monitoring urine output is a non-invasive and straightforward method, making it a preferred choice in clinical settings.

Choice B Reason:
Heart rate can be an indicator of fluid status, but it is less reliable than urine output. Tachycardia (an increased heart rate) can occur due to pain, anxiety, or other stressors, not just fluid deficit. While a decreasing heart rate might suggest improving fluid status, it is not a definitive indicator on its own. Other factors must be considered in conjunction with heart rate to assess fluid resuscitation adequacy.

Choice C Reason:
Blood pressure is another parameter used to assess fluid status, but it can be influenced by many factors, including the patient's baseline blood pressure, medications, and the presence of other medical conditions. While maintaining adequate blood pressure is important, it is not as sensitive or specific as urine output for assessing fluid resuscitation in burn patients. Blood pressure can remain within normal ranges even when fluid resuscitation is inadequate, especially in the early stages.

Choice D Reason:
Mental status can be affected by fluid status, but it is a late indicator of inadequate perfusion. Changes in mental status, such as confusion or decreased level of consciousness, can occur when there is significant hypoperfusion and shock. By the time mental status changes are observed, the patient may already be in a critical state. Therefore, it is not a primary indicator for assessing fluid resuscitation adequacy.

Choice E Reason:
Capillary refill time is a quick and simple test to assess peripheral perfusion. However, it is not as reliable as urine output for evaluating overall fluid status. Capillary refill can be affected by ambient temperature, lighting conditions, and the examiner's technique. While a prolonged capillary refill time can indicate poor perfusion, it is not as specific or sensitive as urine output for assessing fluid resuscitation adequacy.