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?

Question

Quizplus · Accepted Answer

The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss because of the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake,decreased urine output,and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension.

The Nurse Is Caring for a Patient with a Massive