A patient presents to the medical-surgical unit confused and with a blood pressure of 90/50. Which assessment findings would support the nurse's concern that the patient has low cardiac output?
1. Skin tenting (poor turgor) and heart rate 102
2. Pallor and peripheral edema
3. Bounding peripheral pulses and pulse oximeter reading 90%
4. Prolonged capillary refill and diminished peripheral pulses
4
Rationale 1: Poor skin turgor and a heart rate of 102 could indicate dehydration.
Rationale 2: Pallor can be an indication of poor cardiac output; however, there are several causes of peripheral edema other than poor cardiac output, so this finding is not definitive.
Rationale 3: Bounding peripheral pulses indicates good output, although perhaps a rapid heart rate. Oxygen saturation of 90% is on the low side, but accompanied by bounding pulses does not indicate poor output.
Rationale 4: The patient with low cardiac output will have signs of poor circulation, such as prolonged capillary refill and diminished peripheral pulses.
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