Practice Quiz

CMSRN Medical-Surgical Nursing

Category - Hematological

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Nursing care planning is based on the knowledge that the first 24-48 hours post-burn are characterized by:
  1. An increase in the total volume of intracranial plasma
  2. Excessive renal perfusion with diuresis
  3. Fluid shift from interstitial space
  4. Fluid shift from intravascular space to the interstitial space
Explanation
Answer - D - Fluid shift from intravascular space to the interstitial space. This period is the burn shock stage, or the hypovolemic phase. Tissue injury causes vasodilation, which results in increased capillary permeability, making fluids shift from the intravascular to the interstitial space. This can lead to a decrease in circulating blood volume or hypovolemia which decreases renal perfusion and urine output.
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