A patient who was stabbed in the abdomen has received fluid resuscitation of 2 liters over the last hour. Which finding would the nurse evaluate as indicating this intervention has been ineffective?
1. Patient complaints of abdominal pain
2. Patient's request to see a priest
3. Urine output of 45 mL for this hour
4. Heart rate 142 and regular
4
Rationale 1: The patient will likely continue to have abdominal pain even if shock is reversed.
Rationale 2: Level of consciousness is an indicator of the effectiveness of fluid resuscitation. If the patient is alert enough to ask for a priest, it is likely that mental status is more or less normal.
Rationale 3: A urine output of 30 to 50 mL per hour indicates adequate fluid resuscitation.
Rationale 4: Elevation of the heart rate indicates that fluid resuscitation has not been effective.
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