The nurse in the intensive care unit (ICU) is caring for a client diagnosed with acute respiratory distress syndrome (ARDS). Vital signs prior to endotracheal intubation: HR 108 bpm, RR 32 bpm, BP 88/58 mmHg, and oxygen saturation 82%
The client is intubated and placed on mechanical ventilation with positive pressure ventilation. Which assessment finding indicates a further decrease of cardiac output secondary to positive pressure ventilation?
A) Blood pressure 90/60 mmHg
B) Urine output 25mL/hr
C) Heart rate 110 bpm
D) Oxygen saturation 90%
Answer: B
Decreased cardiac output is supported with by a decrease of urine output. Expected urine output is at least 30 mL/hr. This client's urine output is decreased; therefore this finding supports the diagnosis of decreased cardiac output. Although hypotension and tachycardia are indicative of a decreased cardiac output, this is not a change from the previous assessment and would not indicate a further decrease in cardiac output due to mechanical ventilation. The oxygen saturation level is within normal limits for this client and improving from the previous assessment.
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