The nurse is caring for a child who was burned in a house fire. The nurse develops a plan of care for monitoring the child during the treatment for burn shock
The nurse identifies which of the following assessments as providing the most accurate guide to determine the adequacy of fluid resuscitation? 1. Heart rate
2. Lung sounds
3. Level of consciousness
4. Amount of edema at the site of the burn injury
3
Rationale: The sensorium, or level of consciousness, is an important guide to the adequacy of fluid resuscitation. The burn injury itself does not affect the sensorium, so the child should be alert and oriented. Any alteration in sensorium should be evaluated further. A neurological as-sessment would determine the level of consciousness in the child. "Heart rate," "lung sounds," and "amount of edema at the site of the burn injury," although important in the assessment of the child with a burn injury, would not provide an accurate assessment of the adequacy of fluid re-suscitation.
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