The nurse assesses a patient with a penetrating abdominal wound as a Class IV hemorrhage because of which findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Heart rate 160
2. Respiratory rate 28
3. Mean arterial pressure 50
4. Capillary refill 5 seconds
5. Mild decrease in urine output
1,2,3,4
Rationale 1: Heart rate greater than 140 is an indication of Class IV hemorrhage.
Rationale 2: Tachypnea is an indication of Class IV hemorrhage.
Rationale 3: Mean arterial pressure less than 60 is an indication of Class IV hemorrhage.
Rationale 4: Delayed capillary refill is an indication of Class IV hemorrhage.
Rationale 5: Mild decrease in urine output would be seen in a Class II hemorrhage.
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