The Nurse Is Caring for a Patient with a Massive

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.