A patient is admitted for evaluation of hypotension. Which of the following observations by the nurse would require immediate attention?
1. presence of rales at both lung bases
2. pulmonary artery wedge pressure of 2 mm Hg
3. heart rate of 112
4. urine output of 30 cc/hr
2
Rationale: The normal pulmonary artery wedge pressure is 4 to 12 mm Hg. A wedge pressure of 2 mm Hg is indicative of significant hypovolemia. Rales at lung bases are an abnormal finding, but unless the patient has significant respiratory distress, they would not require immediate intervention. Heart rate of 112 is classified as a tachycardia. Although abnormal, this rate is not unduly alarming and would not be a high priority. Urine output of 30 cc/hr is normal.
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