Prepare for your NCLEX-RN® exam with a clinical question about obstructive shock management in the cardiac intensive care unit. Learn to recognize critical findings that require immediate intervention.
The nurse in the cardiac intensive care unit is monitoring a client with obstructive shock. Which clinical finding should the nurse report to the health care provider immediately?
A. Arterial blood pH 7.40
B. Urine output of 45 mL in the past hour
C. +1 bilateral peripheral pulses
D. Alert and oriented x4 Scroll down for the correct answer!
The correct answer to today’s NCLEX-RN® Question is…
C. +1 bilateral peripheral pulses
Rationale: +1 peripheral pulses or cold, clammy skin indicate inadequate cardiac output to maintain peripheral circulation. The nurse should notify the health care provider and anticipate immediate intervention.
Major Takeaway
Obstructive shock is a life-threatening condition that develops when a mechanical obstruction prevents the heart from filling properly or pumping enough blood through the cardiovascular system. This reduces the amount of oxygenated blood that reaches the tissues, causing acute hypoperfusion and tissue hypoxia. The nurse should closely monitor a client with obstructive shock for any signs of complications or a worsening condition. Findings the nurse should immediately report to the health care provider include arterial pH less than 7.35 or bicarbonate less than 21 mEq/L, minimal urine output, decreased peripheral pulses or cold or clammy skin, and altered level of consciousness (LOC), as well as tachycardia, tachypnea, confusion, or headache.
Incorrect answer explanations
A. Arterial blood pH 7.40
Rationale: An arterial blood pH of 7.40 is within the normal parameters of 7.35 to 7.45 and is an expected finding. Therefore this does not need to be reported to the health care provider.
B. Urine output of 45 mL in the past hour
Rationale: An hourly urine output of 45 mL is above the minimum of 30 mL/hr and is an expected finding indicating adequate perfusion to the renal system. Therefore this does not need to be reported to the health care provider.
D. Alert and oriented x4
Rationale: A client who is fully alert and oriented to person, place, time and situation (x4) is an expected finding indicating adequate cerebral perfusion. ________________________
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