When caring for a severely burned client, the nurse notes that the client's urine is dark brown. The priority action by the nurse would be to
A) check the urinary catheter for patency and irrigate it if needed.
B) monitor vital signs more frequently to detect hypovolemia.
C) notify the physician immediately and request an order for urinalysis.
D) titrate intravenous (IV) fluids to maintain urine output of 75-100 ml/hour.

Question

Quizplus · Accepted Answer

The nurse should administer IV fluids at a rate that maintains a urine output of 75-100 ml/hour. Myoglobin and hemoglobin released from the damaged muscles and red blood cells (hemachromogens) all can precipitate in the renal tubules and create acute tubular necrosis. Therefore they need to be vigorously flushed from the body. Checking the urinary catheter for patency is never a wrong intervention, the physician does need to be notified, the nurse may need to request a UA, but the priority action remains titrating the IV fluid rate.

When Caring for a Severely Burned Client, the Nurse Notes