A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
**Core Concept**
In the context of head trauma, the client's urine output of 300 ml/hr, dry skin, and dry mucous membranes indicate signs of dehydration, which can be caused by inadequate fluid replacement and potential third-space fluid shifts. This scenario requires careful fluid management to prevent complications such as hypovolemia, hypotension, and organ dysfunction.
**Why the Correct Answer is Right**
The initial nursing intervention should focus on administering intravenous fluids (IVFs) to restore circulating blood volume and maintain adequate urine output. The choice of IVF is crucial; in this case, a crystalloid solution such as normal saline or lactated Ringer's solution is preferred due to its ability to expand plasma volume and maintain electrolyte balance. The goal is to correct hypovolemia, stabilize vital signs, and prevent further complications.
**Why Each Wrong Option is Incorrect**
**Option A:** Administering diuretics would be inappropriate in this scenario, as they would further increase urine output, exacerbating dehydration and potentially leading to hypovolemia and hypotension.
**Option B:** Monitoring urine output alone is insufficient, as it does not address the underlying cause of dehydration and potential third-space fluid shifts.
**Option C:** Administering vasopressors without addressing the underlying cause of hypotension (in this case, dehydration) may lead to further complications, such as decreased organ perfusion and increased blood pressure variability.
**Clinical Pearl / High-Yield Fact**
In patients with head trauma, it's essential to monitor urine output, serum electrolytes, and central venous pressure (CVP) to guide fluid management and prevent complications.
**Correct Answer:** C. Administering intravenous fluids (IVFs) with a crystalloid solution such as normal saline or lactated Ringer's solution.