Which of the following are the most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with multiple organ dysfunction syndrome?
1. pulse pressure, level of consciousness, and pupillary response
2. breath sounds, blood pressure, and body temperature
3. blood pressure, pulse, and respirations
4. level of consciousness, urine output, and skin color and temperature
4
Rationale: Level of consciousness, urine output, and skin color and temperature is correct because level of consciousness, urine output, and skin color and temperature are maintained as long as the body is perfused and oxygenated. Pulse pressure, level of consciousness, and pupillary response is incorrect because pupillary response depends on an intact cranial nerve III. Breath sounds, blood pressure, and body temperature is incorrect because breath sounds and blood pressure may be normal and tissue perfusion still inadequate depending on the condition of arteries, amount of blood, and exchange at the cellular area. Blood pressure, pulse, and respirations can be caused by the stress response or a compensatory mechanism and do not necessarily determine adequate tissue perfusion.
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