The nurse assesses a 72 kg client six hours after a thermal burn covering 50% of the client's total body surface area. Of the findings listed below, which is the most important to communicate to the health care provider?

Cardiac monitor shows a pulse rate of 204

Serous exudate is leaking from the burns

Urine output is 20 mL for the past 2 hours

Blood pressure is 94/50 per arterial line.

Answer and Explanation

The Correct Answer is C

A. Cardiac monitor shows a pulse rate of 204: A markedly elevated heart rate is expected during the early burn-shock phase due to pain, stress, and circulating catecholamines. Although it indicates a hypermetabolic and hypovolemic state, it is not as specific for inadequate fluid resuscitation as reduced urine output, so it is not the most urgent finding.

B. Serous exudate is leaking from the burns: Plasma leakage from damaged capillaries is normal in the first 24–48 hours after a major burn. While this contributes to hypovolemia, its presence alone does not indicate a worsening condition and does not require immediate provider notification compared with signs of renal hypoperfusion.

C. Urine output is 20 mL for the past 2 hours: This extremely low output is a key indicator of inadequate renal perfusion during the resuscitation period. Clients with major burns should maintain 30–50 mL/hr to ensure the kidneys are receiving adequate circulation, making this the most critical finding to report promptly.

D. Blood pressure is 94/50 per arterial line: Borderline hypotension commonly occurs during early burn shock because of fluid shifts into the interstitial space. Although concerning, it is less reliable than urine output for assessing end-organ perfusion.

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Correct Answer is A

Explanation

A. hemorrhage from esophageal varices: Portal hypertension increases pressure in the portal venous system, leading to esophageal varices that can rupture. Massive bleeding from varices is life-threatening and requires immediate intervention, making this the most critical complication to monitor.

B. liver abscess: Liver abscesses can occur in clients with liver disease but are less immediately life-threatening than variceal bleeding. They develop over time and usually present with fever and localized pain rather than sudden hemorrhage.

C. hemorrhage from duodenal diverticulitis: Duodenal diverticulitis is rare and not a common complication of portal hypertension. While it can cause bleeding, it is not the primary life-threatening concern in this population.

D. small bowel obstruction: Small bowel obstruction is not directly associated with portal hypertension. Although it can cause significant complications, it is not an immediate risk in these clients.

A. Perform a halo test B. Instruct the client to blow his nose and check the nares for inflammation. C. Obtain a specimen of the fluid for culture and sensitivity. D. Check the nasal drainage for glucose.

Correct Answer is A

Explanation

A. Perform a halo test: Clear nasal drainage in a client with periorbital ecchymosis may indicate cerebrospinal fluid (CSF) leakage. The halo or ring test helps differentiate CSF from normal nasal secretions, which is critical for detecting a basilar skull fracture. Early identification guides further neurologic assessment and prevents complications.

B. Instruct the client to blow his nose and check the nares for inflammation: Blowing the nose can increase intracranial pressure and worsen CSF leakage. Assessing for inflammation does not confirm CSF presence and may be harmful in suspected skull fractures.

C. Obtain a specimen of the fluid for culture and sensitivity: Culturing the fluid is unnecessary initially and may delay urgent assessment. Identifying CSF leakage takes priority to prevent infection and guide immediate care.

D. Check the nasal drainage for glucose: Glucose testing can suggest CSF, but the halo test provides a more rapid and reliable bedside assessment. Confirming CSF leakage quickly is essential for early intervention.

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The nurse assesses a 72 kg client six hours after a thermal burn covering 50% of the client's total body surface area. Of the findings listed below, which is the most important to communicate to the health care provider?

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