The nurse in the intensive care unit (ICU)is caring for a client diagnosed with acute respiratory distress syndrome (ARDS).Vital signs prior to endotracheal intubation: HR 108 bpm,RR 32 bpm,BP 88/58 mmHg,and oxygen saturation 82%.The client is intubated and placed on mechanical ventilation with positive pressure ventilation.Which assessment finding indicates a further decrease of cardiac output secondary to positive pressure ventilation?
A) Blood pressure 90/60 mmHg
B) Urine output 25mL/hr
C) Heart rate 110 bpm
D) Oxygen saturation 90%

Question

Quizplus · Accepted Answer

A) Decreased cardiac output is supported with by a decrease of urine output. Expected urine output is at least 30 mL/hr. This client's urine output is decreased; therefore this finding supports the diagnosis of decreased cardiac output. Although hypotension and tachycardia are indicative of a decreased cardiac output, this is not a change from the previous assessment and would not indicate a further decrease in cardiac output due to mechanical ventilation. The oxygen saturation level is within normal limits for this client and improving from the previous assessment.
B) Decreased cardiac output is supported with by a decrease of urine output. Expected urine output is at least 30 mL/hr. This client's urine output is decreased; therefore this finding supports the diagnosis of decreased cardiac output. Although hypotension and tachycardia are indicative of a decreased cardiac output, this is not a change from the previous assessment and would not indicate a further decrease in cardiac output due to mechanical ventilation. The oxygen saturation level is within normal limits for this client and improving from the previous assessment.
C) Decreased cardiac output is supported with by a decrease of urine output. Expected urine output is at least 30 mL/hr. This client's urine output is decreased; therefore this finding supports the diagnosis of decreased cardiac output. Although hypotension and tachycardia are indicative of a decreased cardiac output, this is not a change from the previous assessment and would not indicate a further decrease in cardiac output due to mechanical ventilation. The oxygen saturation level is within normal limits for this client and improving from the previous assessment.
D) Decreased cardiac output is supported with by a decrease of urine output. Expected urine output is at least 30 mL/hr. This client's urine output is decreased; therefore this finding supports the diagnosis of decreased cardiac output. Although hypotension and tachycardia are indicative of a decreased cardiac output, this is not a change from the previous assessment and would not indicate a further decrease in cardiac output due to mechanical ventilation. The oxygen saturation level is within normal limits for this client and improving from the previous assessment.

The Nurse in the Intensive Care Unit (ICU)is Caring for a Client