Nurse Ron is assessing a client admitted with second and third-degree burns on the face, arms, and chest. Which finding indicates a potential problem?
A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg.
B. Urine output of 20 ml/hour.
C. White pulmonary secretions.
D. Rectal temperature of 100.6° F (38° C).
Correct Answer: B. Urine output of 20 ml/hour.
A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume deficit.
Option A: This client’s PaO2 value falls within the normal range (80 to 100 mm Hg).
Option C: White pulmonary secretions indicate the presence of large numbers of white blood cells, especially neutrophilic granulocytes.
Option D: The client’s rectal temperature isn’t significantly elevated and probably results from the fluid volume deficit.