A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication?
a. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg
b. Urine output of 20 mL/hr
c. Productive cough with white pulmonary secretions
d. Core temperature of 100.6 ° F (38 ° C)
ANS: B
A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the client may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other manifestations are not complications of burn injuries.
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