The nurse is caring for a patient who is undergoing fluid replacement after being burned on 37% of the body. Nursing assessment reveals a blood pressure of 80/60 mm Hg, heart rate of 120 beats/min, and urine output of 10 mL over the past hour
The nurse reports assessment findings to the physician and anticipates which of the following orders?
a. Increase the amount of IV fluid administered per hour.
b. Decrease the amount of IV fluid administered per hour.
c. Change the IV fluid to dextrose and water.
d. Discontinue the IV fluid infusion.
ANS: A
In the first 48 hours after a burn, fluid shifts lead to hypovolemia and, if untreated, hypovolemic shock. Low blood pressure, elevated pulse, and low urine output indicate hypovolemia, so the nurse should anticipate increasing IV fluids. Decreasing or discontinuing fluids is inappropriate, and dextrose and water is hypotonic and will not maintain circulating volume.
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