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Exam (elaborations)
Med Surge 4Th Edition
1. The nurse is caring for a client with deficient fluid volume caused by a massive burn injury. 
Which of the following assessment data will be of greatest concern to the nurse? 
a. The 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. - correct answer : A 
The blood pressure indicates that the client may be developing hypovolemic shock as a result 
of fluid los...