When caring for a patient weighing 60 kg who has just been admitted with septic shock, which of these assessment data greatest concern to the nurse?
Arterial oxygen saturation is 90%.
Urine output 15 ml for 2 hours.
Apical pulse 110 beats/min.
BP 94/56 mm Hg.
The Correct Answer is D
Septic shock is a life-threatening condition characterized by severe infection, systemic inflammation, and inadequate tissue perfusion. Hypotension, as indicated by a low blood pressure reading, is a significant concern in septic shock. It reflects inadequate perfusion to vital organs and tissues, leading to potential organ dysfunction and damage.
While all the assessment data provided may be important and require attention, the low blood pressure (BP) reading indicates impaired systemic perfusion and can contribute to end-organ damage. The nurse should prioritize interventions aimed at improving perfusion and stabilizing the patient's blood pressure.
A. Arterial oxygen saturation is 90% in (option A) is incorrect because While an arterial oxygen saturation of 90% is below the desired range, it is not as immediately life-threatening as low blood pressure. Oxygen therapy and interventions to improve oxygenation should still be initiated, but addressing hypotension takes priority.
B. Urine output of 15 ml for 2 hours in (option B) is incorrect because Decreased urine output is a concerning sign, as it may indicate impaired renal perfusion. However, the immediate concern in septic shock is addressing the low blood pressure to improve overall perfusion, including renal perfusion.
C. Apical pulse 110 beats/min in (option C) is incorrect because: Tachycardia is a common finding in septic shock and represents the body's compensatory response to maintain cardiac output. While it requires monitoring and consideration, low blood pressure is a more significant concern.
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Related Questions
Correct Answer is C
Explanation
Urine output is an essential indicator of renal perfusion and overall fluid status. In a patient in shock, maintaining an adequate urine output is a crucial goal of fluid resuscitation. A urine output of 0.5 to 1 mL/kg/hour is generally considered adequate in adults. The given value of 35 ml over the last hour suggests that the patient is producing urine, which indicates that fluid resuscitation is effective in restoring perfusion to the kidneys.
A. The patient's mean arterial pressure (MAP) is 50 mm Hg in (option A) is incorrect because While mean arterial pressure is an important hemodynamic parameter, a single value alone may not provide a comprehensive assessment of the patient's response to fluid resuscitation.
B. The patient's GCS score is 9 in (option B) is incorrect because The Glasgow Coma Scale (GCS) assesses the level of consciousness and neurological function but does not directly reflect fluid resuscitation effectiveness.
D. The patient's hemoglobin is within normal limits: (option D) is incorrect because Haemoglobin levels are important for assessing oxygen-carrying capacity but do not directly indicate the effectiveness of fluid resuscitation.
Therefore, the nurse can evaluate that fluid resuscitation for a 70 kg patient in shock is effective by observing a urine output of 35 ml over the last hour.
Correct Answer is B
Explanation
Systemic vascular resistance represents the resistance to blood flow in the systemic circulation. It is an important indicator of afterload, which is the force against which the left ventricle must pump to eject blood into the systemic circulation. By monitoring the changes in SVR, the nurse can assess the impact of medications aimed at reducing left ventricular afterload.
A. Pulmonary artery wedge pressure (PAWP) in (option A) is incorrect because: PAWP is a measure of left ventricular preload and reflects the pressure within the left atrium and left ventricle at end-diastole. It is not specifically related to afterload reduction.
C. Pulmonary vascular resistance (PVR) in (option C) is incorrect because: PVR represents the resistance to blood flow in the pulmonary circulation. It is not directly related to left ventricular afterload.
D. Central venous pressure (CVP) in (option D) is incorrect because: CVP reflects the pressure in the right atrium and is an indicator of right-sided cardiac function. It is not specifically related to left ventricular afterload reduction.
Therefore, to assess the effectiveness of medications in reducing left ventricular afterload, the nurse should monitor the systemic vascular resistance (SVR).
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