When caring for the client in septic shock, the nurse recognizes fluid replacement is inadequate when which of the following is noted?
1. Urine output 10 milliliters for the last hour
2. Pulse rate of 100 beats per minute
3. MAP 75
4. Central venous pressure is 5 mmHG
Urine output 10 milliliters for the last hour
Rationale: Adequate blood flow to the kidneys is measured by urine output of 0.5 ml/kg/hour. A heart rate of 100 is considered acceptable in shock. MAP should be kept > 65 mmHG. Normal CVP is 4 to 12.
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