Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider?
a. Blood pressure is 95/48 per arterial line.
b. Serous exudate is leaking from the burns.
c. Cardiac monitor shows a pulse rate of 108.
d. Urine output is 20 mL per hour for the past 2 hours.
ANS: D
The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase.
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