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.

Question

Quizplus · Accepted Answer

The blood pressure indicates that the client may be developing hypovolemic shock as a result of fluid loss. This 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 client's fluid intake but not as urgently as the hypotension.

The Nurse Is Caring for a Client with Deficient Fluid