The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis.To evaluate the effectiveness of fluid therapy,which physiological parameters would be most important for the nurse to assess?
A) Breath sounds and capillary refill
B) Blood pressure and oral temperature
C) Oral temperature and capillary refill
D) Right atrial pressure and urine output

Question

Quizplus · Accepted Answer

Early goal-directed therapy includes administration of IV fluids to keep central venous pressure at 8 mm Hg or greater.Combined with urine output,fluid therapy effectiveness can be adequately assessed.Evaluation of breath sounds assists with determining fluid overload in a patient but does not evaluate the effectiveness of fluid therapy.Capillary refill provides a quick assessment of the patient's overall cardiovascular status,but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems.Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock.Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock.Capillary refill provides a quick assessment of the patient's overall cardiovascular status,but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems.

The Nurse Has Been Administering 0