A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?

Rationale:
A. Dextrose 5% in water (D5W) is a hypotonic solution that primarily provides free water for hydration. It is not appropriate for initial burn resuscitation because it does not replace the large volume of electrolytes lost from the intravascular space due to fluid shifts and third-spacing.

B. Dextrose 5% in 0.9% sodium chloride (D5NS) contains both glucose and sodium but is not typically used in the first 24 hours of burn resuscitation. The glucose component is unnecessary initially, and isotonic replacement with electrolytes is preferred.

C. 0.9% sodium chloride (normal saline) is an isotonic solution and can be used for volume expansion. However, it does not contain the electrolytes (like lactate) that help buffer metabolic acidosis, which is common after extensive burns.

D. Lactated Ringer's (LR) is the preferred fluid for the first 24 hours after a burn injury. LR is isotonic, contains electrolytes similar to plasma (sodium, potassium, calcium, and chloride), and includes lactate, which is metabolized to bicarbonate and helps counteract metabolic acidosis from tissue hypoperfusion. It is used with formulas like the Parkland formula to calculate precise fluid replacement volumes.

Rationale:
A. Placing the patient in high-Fowler’s position is incorrect because while it can improve ventilation, the disappearance of wheezes with decreased or absent breath sounds may indicate progressive airway obstruction, which is life-threatening and requires immediate provider notification. Positioning alone will not prevent airway compromise.

B. Encouraging the patient to cough and auscultating again is incorrect because the patient may have airway edema from inhalation injury, and attempting to cough may not relieve obstruction or alert staff to impending respiratory failure. This delays urgent intervention.

C. Documenting the results and continuing to monitor is incorrect because absent or decreased breath sounds in a patient with inhalation injury is an emergency. Waiting could result in complete airway obstruction and respiratory arrest.

D. Notifying the health care provider is correct because the loss of previously audible wheezes and decreased lung sounds indicates worsening airway edema or obstruction, which requires immediate evaluation and possible airway intervention (e.g., intubation). Rapid assessment and provider notification are critical to prevent respiratory failure.