44. A client with acute pancreatitis and fluid volume deficit is in an ICU. Which assessment finding should a nurse report to a physician?
44. A client with acute pancreatitis and fluid volume deficit is in an ICU. Which assessment finding should a nurse report to a physician?
. Urine output of 35 mL/hr.
. CVP of 12 mm Hg.
. Cardiac output of 5 L/min.
. Decreased pain in the fetal position.
Test-Taking Tip
"Report to a physician" means something is wrong. The question addresses both the disease and fluid volume. Know normal values (Answers 1 and 3); Answer 2 is the only abnormal value. Answer 4 addresses only the disease and not the fluid volume.
Content Area: Adult Health, Fluid and Electrolyte Imbalances; Integrated Process: Nursing Process, Evaluation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Laboratory Values
.
Answer 1 is incorrect because the urine output is within the normal range. Answer 2 is correct because the normal central venous pressure (CVP) is 0 to 8 mm Hg. A value of 12 mm Hg reflects hypervolemia. The right ventricular function of this client reflects fluid volume overload, and the physician should be alerted. Answer 3 is incorrect because the cardiac output is within the normal range of 4 to 6 L/min. Answer 4 is incorrect because this position, as well as leaning forward or sitting, helps decrease the pain from acute pancreatitis. The RN should foster a comfortable yet safe position.