An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor to prevent a complication of this injury? (Select all that apply.)
a. Temperature
b. Urinary output
c. Blood pressure
d. Pupil reaction
e. Skin color
ANS: B, C, E
With a pelvic fracture, internal organ damage may result in bleeding and hypovolemic shock. The nurse monitors the client's heart rate, blood pressure, urine output, skin color, and level of consciousness frequently to determine whether shock is manifesting. It is important to monitor the urine for blood to assess whether the urinary system has been damaged with the pelvic fracture. Changes in temperature and pupil reactions are not directly associated with hypovolemic shock. Temperature changes are usually associated with hypo- or hyperthermia or infectious processes. Pupillary changes occur with brain injuries, bleeds, or neurovascular accidents.
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