A person who weighs approximately 80 kg is brought to the emergency department with a stab wound
Which assessment findings would the nurse evaluate as indicating this patient has lost more than 30% of total blood volume? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Blood pressure 78 mmHg systolic
2. Heart rate 118 bpm
3. Dry, hot skin
4. Loss of consciousness when trying to sit up on the gurney
5. Slight restlessness with complaint of pain
1,4
Rationale 1: A blood pressure of 70–90 mmHg systolic indicates significant blood loss, approximately 30% to 40%.
Rationale 2: The heart rate would probably be over 120 beats per minute if over 30% of total blood volume were lost.
Rationale 3: Significant blood loss typically results in cool or cold skin that may be clammy.
Rationale 4: Syncope on sitting or standing is associated with blood loss of 30 to 40%.
Rationale 5: Slight restlessness would indicate a lesser amount of blood loss, perhaps less than 20%.
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