When monitoring initial fluid replacement forthe patient with 40% TBSA deep partial-thickness and full-thickness burns, which findingis of most concern to the nurse? a) Serum K+ of 4.5 mEq/L b) Urine output of 35 mL/hr c) Decreased bowel sounds d) Blood pressure of 86/72 mm Hgd Rationale: Adequacy of fluid replacement isassessed by urine output and cardiac parameters.Urine output should be 0.5 to 1 mL/kg/hr. Meanarterial pressure should be >65 mm Hg, systolic BP>90 mm Hg, and heart rate <120 beats/min. A bloodpressure of 86/72 indicates inadequate fluidreplacement. However, the MAP is calculated at 77mm Hg.

During the emergent phase of burn injury, the nurseassesses for the presence of hypovolemia. In burnpatients, hypovolemia occurs primarily as a result of d. Capillary permeability with fluid shift to theinterstitium. d A patient is to undergo skin grafting with the use of culturedepithelial autografts full-thickness burns. The nurse explains tothe patient that this treatment involves When assessing a patient who spilled hot oil on theright leg and foot, the nurse notes that the skin is dry,pale, hard skin. The patient states that the burn is notpainful. What term would the nurse use to documentthe burn depth?