On the first day following a severe burn, the body's fluid reserves have left the circulating volume and entered the interstitial space, causing massive edema. What should the nurse monitor for very closely in the burn victim?
a. Increasing intracranial pressure
b. Reduced urine output
c. Eschar formation
d. Fluid overload
ANS: B
With the fluid shift associated with severe burns, the nurse must be observant for the reduction of urine, an indication of altered renal function.
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