A critically ill patient is admitted for the treatment of sepsis. The right arterial BP is 90/60, the central venous pressure is 2, and the pulmonary arterial pressure is 20/8. What assessment can the nurse make from this data?
1. The patient may require additional fluids because all pressures are low.
2. The patient is stable and should continue to be monitored hourly due to the presence of sepsis.
3. The pressure in the lungs is high even though the other pressures are low. The doctor should be notified and STAT X-ray expected.
4. The pressure in the right atrium is 2, which is inaccurate. The line should be flushed and re-zeroed before an evaluation can be made.
The patient may require additional fluids because all pressures are low.
Rationale: The arterial, central venous, and pulmonary arterial pressures are all low. Sepsis is a type of distributive shock. The nurse would expect to give a fluid bolus in this situation as well as initiate or continue other therapies for sepsis.
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