The nurse is caring for a patient in the initial phase of treatment for a partial-thickness burn. The patient has been stabilized, with blood pressure 140/88 mm Hg, pulse 78 beats/min, respirations 22 breaths/min, and temperature 97.4°F (36.3°C)
Which new assessment finding should be immediately communicated to the RN or physician?
a. Blood pressure 122/74 mm Hg
b. Temperature 99°F (37.2°C)
c. Report of increasing pain
d. Serum-filled blister formation
ANS: A
A patient with a burn is at risk for fluid volume deficit, and a dropping blood pressure, even though it is still within normal limits, could be an early sign. Temperature and pain are concerns but are not immediately life threatening. Blister formation is expected.
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