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. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which

assessment data will be of most concern to the nurse?

a. Blood pressure is 90/40 mm Hg.

b. Urine output is 30 mL over the last hour.

c. Oral fluid intake is 100 mL for the last 8 hours.

d. There is prolonged skin tenting over the sternum.

ANS: A

The blood pressure indicates that the patient may be developing hypovolemic shock as a result

of intravascular fluid loss due to the burn injury. This ...
Medical-Surgical-Nursing-Patient-Centered-Collaborative-Care-Single-Volume-7th-Edition-Test-Bank
Last document update:
ago
. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which

assessment data will be of most concern to the nurse?

a. Blood pressure is 90/40 mm Hg.

b. Urine output is 30 mL over the last hour.

c. Oral fluid intake is 100 mL for the last 8 hours.

d. There is prolonged skin tenting over the sternum.

ANS: A

The blood pressure indicates that the patient may be developing hypovolemic shock as a result

of intravascular fluid loss due to the burn injury. This ...
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