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The nurse cares for a 55-year-old female admitted to the bur…

Posted byAnonymous October 24, 2024October 25, 2024

Questions

The nurse cаres fоr а 55-yeаr-оld female admitted tо the burn unit following a house fire.  Nurses’ Notes   2000: A 55- year-old female arrives to  the emergency department via ambulance with bilateral superficial partial thickness and deep partial thickness burns to the front of both legs, the entire right arm and the chest from a house fire that occurred at 1800 today. Client weighs 242 lbs.  Fluid resuscitation started with Lactated Ringer's IV in the emergency department. 2100:  Admitted to the burn unit. Vital signs as noted. Morphine sulfate given for pain.  Breath sounds clear.  Client begins to appear edematous. Doppler pedal pulses present. A triple-lumen subclavian central venous line has been inserted to monitor the client’s central venous pressure (CVP). Vital Signs   Time 2000 2100   Temperature 37.8 C/100 F 37.1 C/98.9 F   Heart rate 130 135   Respirations 28 32   Blood pressure 88/58 80/54   Pulse oximeter 92 on 4L NC 98 on 100%  Non-Rebreather (NRB)   Pain 6/10 4/10   CVP   3 mmHg   Intake & Output   Hour 2000 2100   IV rate As ordered As ordered   IV intake Started 689 mL   Output   20 mL     Which five client findings would be most important for the nurse to report to the healthcare provider immediately? Select all that apply

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