A client presents to the medical?surgical unit confused and with a blood pressure of 90/50. The nurse does a quick physical assessment upon the client's arrival to the unit to determine if the cause of confusion is cardiac in nature
Which of the following assessment findings might indicate low cardiac output? 1. Prolonged capillary refill and diminished peripheral pulses
2. Bounding peripheral pulses and pulse oximeter reading 90%
3. Pallor and peripheral edema
4. Skin tenting (poor turgor) and heart rate 102
Prolonged capillary refill and diminished peripheral pulses
Rationale: The client with low cardiac output will have signs of poor circulation, such as prolonged capillary refill and diminished peripheral pulses. Bounding peripheral pulses indicates good output, though perhaps a rapid heart rate. Oxygen saturation of 90% is on the low side, but accompanied by bounding pulses will not indicate poor output. Pallor can be an indication of poor output; however, there are several causes of peripheral edema other than just poor cardiac output, so this answer choice is not definitive. Poor skin turgor and heart rate of 102 could indicate dehydration.
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