The nurse is caring for a client who is receiving mechanical ventilation accompanied by positive end-expiratory pressure (PEEP). What assessment findings require immediate intervention?
a. Blood pressure drop from 110/90 mm Hg to 80/50 mm/Hg
b. Pulse oximetry value of 96%
c. Arterial blood gas (ABG): pH, 7.40; PaO2, 80 mm Hg; PaCO2, 45 mm Hg; HCO3–, 26 mEq/L
d. Urinary output of 30 mL/hr
A
Increased intrathoracic pressure can inhibit blood return to the heart and cause decreased cardiac output. This manifests with a drop in blood pressure. The pulse oximetry reading, ABGs, and urinary output are all normal.
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