The nurse is assessing the client experiencing shock, and notes that the client's urinary output is 20 mL/hour. The nurse concludes the client:
1. Has decreased blood flow to the kidneys.
2. Is experiencing liver failure.
3. Might be experiencing acute respiratory distress syndrome.
4. Is experiencing disseminated intravascular coagulation.
Answer: 1
1. The urinary output will decrease when blood flow to the kidneys is shunted away from the kidneys to protect the brain and heart.
2. Jaundice would be a sign that the client is in liver failure.
3. The client experiencing respiratory distress syndrome shows signs of decreased oxygenation, such as cyanosis.
4. The client with disseminated intravascular coagulation will have bleeding around catheter sites, in the urine, and in stools, as well as in other areas of the body.
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