Test bank for introduction to critical care nursing 6th edition by sole

https://getbooksolutions.com Link full download:https://getbooksolutions.com/download/test-bank-forintroduction-to-critical-care-nursing-6th-edition-by-sole Test Bank for Introduction to Critical Care Nursing 6th Edition by Sole Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome Test Bank MULTIPLE CHOICE The nurse is caring for a patient admitted with hypovolemic shock The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure What is the best nursing action? a Assess the blood pressure by Doppler b Estimate the systolic pressure as 60 mm Hg c Obtain an electronic blood pressure monitor d Record the blood pressure as “not assessable.” ANS: A Auscultated blood pressures in shock may be significantly inaccurate due to vasoconstriction If blood pressure is not audible, the approximate value can be assessed by palpation or ultrasound If brachial pulses are palpable, the approximate measure of systolic blood pressure is 80 mm Hg This action has the potential to delay further assessment of a compromised patient in shock https://getbooksolutions.com Documenting a blood pressure as not assessable is not appropriate without further attempts using different modalities DIF: Cognitive Level: Application REF: p 258 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis One hour later, which laboratory result requires immediate nursing action? a Creatinine 1.0 mg/dL b Lactate mmol/L c Potassium 3.8 mEq/L d Sodium 140 mEq/L ANS: B Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy of resuscitation in shock, and as an outcome predictor All other listed values are within normal limits and not require additional follow-up https://getbooksolutions.com DIF: Cognitive Level: Application REF: p 259 | Laboratory Alert OBJ: Relate assessment findings to the classification and stage of shock TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a Breath sounds and capillary refill b Blood pressure and oral temperature c Oral temperature and capillary refill d Right atrial pressure and urine output ANS: D Early goal-directed therapy includes administration of IV fluids to keep central venous pressure at mm Hg or greater Combined with urine output, fluid therapy effectiveness can be adequately assessed Evaluation of breath sounds assists with determining fluid overload in a patient but does not evaluate the effectiveness of fluid therapy Capillary refill provides a quick assessment of the patient’s overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in https://getbooksolutions.com shock Capillary refill provides a quick assessment of the patient’s overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems DIF: Cognitive Level: Application REF: p 282 OBJ: Describe management strategies for each classification of shock TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies A patient is admitted to the critical care unit following coronary artery bypass surgery Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is mm Hg; cardiac output is L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr What is the best interpretation by the nurse? a The assessed values are within normal limits b The patient is at risk for developing cardiogenic shock c The patient is at risk for developing fluid volume overload d The patient is at risk for developing hypovolemic shock ANS: D https://getbooksolutions.com Vital signs and hemodynamic values assessed collectively include classic signs and symptoms of hypovolemia Both urine output and chest drainage values are high, contributing to the hypovolemia Assessed values are not within normal limits A cardiac output of L/min is not indicative of cardiogenic shock The patient is at risk for hypovolemia, not volume overload, as evidenced by excessive hourly chest drainage and urine output DIF: Cognitive Level: Analysis REF: p 270 | Table 11-5 OBJ: Relate assessment findings to the classification and stage of shock TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk A patient is admitted after collapsing at the end of a summer marathon She is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg The nurse anticipates administering which therapeutic intervention? a Human albumin infusion b Hypotonic saline solution c Lactated Ringer’s bolus d Packed red blood cells ANS: C https://getbooksolutions.com The patient is experiencing symptoms of hypovolemic shock Isotonic crystalloids, such as normal saline and lactated Ringer’s solutions, are the priority intervention Albumin and plasma protein fraction (Plasmanate) are naturally occurring colloid solutions that are infused when the volume loss is caused by a loss of plasma rather than blood, such as in burns, peritonitis, and bowel obstruction Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema and are not used for fluid resuscitation There is no evidence to support a transfusion in the given scenario DIF: Cognitive Level: Analysis REF: p 270 | Table 11-5 OBJ: Describe management strategies for each classification of shock TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies The nurse is caring for a patient in the early stages of septic shock The patient is slightly confused and flushed, with bounding peripheral pulses Which hemodynamic values is the nurse most likely to assess? a High pulmonary artery occlusive pressure and high cardiac output b High systemic vascular resistance and low cardiac output c Low pulmonary artery occlusive pressure and low cardiac output d Low systemic vascular resistance and high cardiac output https://getbooksolutions.com ANS: D As a consequence of the massive vasodilation associated with septic shock, in the early stages, cardiac output is high with low systemic vascular resistance In septic shock, pulmonary artery occlusion pressure is not elevated In the early stages of septic shock, systemic vascular resistance is low and cardiac output is high In the early stages of septic shock, cardiac output is high DIF: Cognitive Level: Knowledge REF: p 270 | Table 11-5 OBJ: Relate assessment findings to the classification and stage of shock TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation The nurse is caring for a patient admitted with severe sepsis Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a right atrial pressure (RAP) of mm Hg Assuming physician orders, which intervention should the nurse carry out first? a Acetaminophen suppository b Blood cultures from two sites c IV antibiotic administration d Isotonic fluid challenge https://getbooksolutions.com ANS: D Early goal-directed therapy in severe sepsis includes administration of IV fluids to keep RAP/CVP at mm Hg or greater (but not greater than 15 mm Hg) and heart rate less than 110 beats/min Fluid resuscitation to restore perfusion is the immediate priority Broad-spectrum antibiotics are recommended within the first hour; however, volume resuscitation is the priority in this scenario DIF: Cognitive Level: Analysis REF: p 270 OBJ: Describe management strategies for each classification of shock TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies Which patient being cared for in the emergency department is most at risk for developing hypovolemic shock? a A patient admitted with abdominal pain and an elevated white blood cell count b A patient with a temperature of 102° F and a general dermal rash c A patient with a 2-day history of nausea, vomiting, and diarrhea d A patient with slight rectal bleeding from inflamed hemorrhoids https://getbooksolutions.com ANS: C Excessive external loss of fluid may occur through the gastrointestinal tract via vomiting and diarrhea, which may lead to hypovolemia There is no evidence to support significant fluid loss in the remaining patient scenarios DIF: Cognitive Level: Comprehension REF: p 270 OBJ: Relate assessment findings to the classification and stage of shock TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential The nurse is caring for a patient admitted with cardiogenic shock Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2 What is the priority pharmacological intervention? a Dobutamine (Dobutrex) b Furosemide (Lasix) c Phenylephrine (Neo-Synephrine) d Sodium nitroprusside (Nipride) https://getbooksolutions.com ANS: A Positive inotropic agents (e.g., dobutamine) are given to increase the contractile force of the heart As contractility increases, cardiac output and index increase and improve tissue perfusion Administration of furosemide will assist only in managing fluid volume overload Phenylephrine administration enhances vasoconstriction, which may increase afterload and further reduce cardiac output Sodium nitroprusside is given to reduce afterload There is no evidence to support a need for afterload reduction in this scenario DIF: Cognitive Level: Analysis REF: p 265 | Table 11-4 OBJ: Describe management strategies for each classification of shock TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 10 Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min What is the priority intervention? a Diphenhydramine (Benadryl) 50 mg intravenously b Epinephrine to mL of a 1:10,000 solution intravenously c Methylprednisolone (Solu-Medrol) 125 mg intravenously d Ranitidine (Zantac) 50 mg intravenously https://getbooksolutions.com 21 The nurse is caring for a patient in septic shock The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102° F The physician orders stat administration of an antibiotic Which additional physician order should the nurse complete first? a Blood cultures b Chest x-ray c Foley insertion d Serum electrolytes ANS: A Timely identification of the causative organism through blood cultures and the initiation of appropriate antibiotics following obtaining blood cultures improve the survival of patients with sepsis or septic shock A chest x-ray, Foley insertion, and measurement of serum electrolytes may be included in the plan of care but are not the priority in this scenario DIF: Cognitive Level: Analysis REF: p 282 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk https://getbooksolutions.com 22 The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe sepsis As part of this patient’s care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team? a Frequent turning b Monitoring intake and output c Enteral feedings d Pain management ANS: C Initiation of enteral feedings within 24 to 48 hours of admission is critical in reducing the risk of infection by assisting in maintaining the integrity of the intestinal mucosa Monitoring intake and output, frequent turning, and pain management are important aspects of care but are not a critical priority during the first 24 to 48 hours following admission DIF: Cognitive Level: Analysis REF: p 268 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk https://getbooksolutions.com 23 The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a patient admitted in severe sepsis What findings assessed by the nurse indicate an appropriate response to therapy? a Normal body temperature b Balanced intake and output c Adequate pain management d Urine output of 0.5 mL/kg/hr ANS: D Adequate urine output of at least 0.5 mL/ kg/hr indicates adequate perfusion to the kidneys following administration of fluid to enhance circulating blood volume Normal body temperature and adequate pain management are not assessment findings indicating an adequate response to fluid therapy During fluid resuscitation in severe sepsis, intake and output will not be balanced as circulating fluid volume deficit is restored DIF: Cognitive Level: Comprehension REF: p 268 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Adaptation https://getbooksolutions.com 24 The nurse is caring for a 70-kg patient in hypovolemic shock Upon initial assessment, the nurse notes a blood pressure of 90/50 mm Hg, heart rate 125 beats/min, respirations 32 breaths/min, central venous pressure (CVP/RAP) of mm Hg, and urine output of mL during the past hour Following physician rounds, the nurse reviews the orders and questions which order? a Administer acetaminophen (Tylenol) 650-mg suppository prn every hours for pain b Titrate dopamine (Intropin) intravenously for blood pressure < 90 mm Hg systolic c Complete neurological assessment every hours for the next 24 hours d Administer furosemide (Lasix) 20 mg IV every hours for a CVP > 20 mm Hg ANS: B Vasoconstrictive agents should not be administered for hypotension in the presence of circulation fluid volume deficit The nurse should question the use of the dopamine (Intropin) infusion All other listed orders are appropriate and have potential for use in the treatment of a hypovolemic shock DIF: Cognitive Level: Analysis REF: Table 11-4 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Reduction of Risk https://getbooksolutions.com 25 The nurse is administering intravenous norepinephrine (Levophed) at mcg/kg/min via a 20-gauge peripheral intravenous (IV) catheter What assessment finding requires immediate action by the nurse? a Blood pressure 100/60 mm Hg b Swelling at the IV site c Heart rate of 110 beats/min d Central venous pressure (CVP) of mm Hg ANS: B Swelling at the IV site is indicative of infiltration Infusion of norepinephrine (Levophed) through an infiltrated IV site can lead to tissue necrosis and requires immediate intervention by the nurse A blood pressure of 100/60 mm Hg, heart rate of 110 beats/min, and a CVP of mm Hg are adequate and not require immediate intervention DIF: Cognitive Level: Comprehension REF: Table 11-4 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk https://getbooksolutions.com 26 The nurse is caring for a patient in cardiogenic shock experiencing chest pain Hemodynamic values assessed by the nurse include a cardiac index (CI) of 2.5 L/min/m2, heart rate of 70 beats/min, and a systemic vascular resistance (SVR) of 2200 dynes/sec/cm-5 Upon review of physician orders, which order is most appropriate for the nurse to initiate? a Furosemide (Lasix) 20 mg intravenous (IV) every hours as needed for CVP > 20 mm Hg b Nitroglycerin infusion titrated at a rate of 5-10 mcg/min as needed for chest pain c Dobutamine (Dobutrex) infusion at a rate of 2-20 mcg/kg/min as needed for CI < L/min/m2 d Dopamine (Intropin) infusion at a rate of 5-10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg ANS: B The patient is complaining of chest pain and has an elevated systemic vascular resistance (SVR) To reduce afterload, ease the workload of the heart, and dilate the coronary arteries, improving oxygenation to the heart muscle, initiation of a nitroglycerin infusion is most appropriate Assessment data not support the initiation of other listed physician order options DIF: Cognitive Level: Analysis REF: Table 11-4 https://getbooksolutions.com OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 27 The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC) What action by the nurse best protects against the development of a central line–associated bloodstream infection (CLABSI)? a Documentation of insertion date b Elevation of the head of the bed c Assessment for weaning readiness d Appropriate sedation management ANS: A Interventions that have been associated with a reduction in CLABSI include timely removal of unnecessary central lines Documentation of the line insertion date will assist in monitoring this measure Elevation of the head of the bed, assessment for weaning readiness, and appropriate sedation management are appropriate interventions to reduce the risk of ventilator-acquired pneumonia DIF: Cognitive Level: Application REF: p 282 https://getbooksolutions.com OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control 28 The nurse is caring for a patient admitted with the early stages of septic shock The nurse assesses the patient to be tachypneic, with a respiratory rate of 32 breaths/min Arterial blood gas values assessed on admission are pH 7.50, CO2 28 mm Hg, HCO3 26 Which diagnostic study result reviewed by the nurse indicates progression of the shock state? a pH 7.40, CO2 40, HCO3 24 b pH 7.45, CO2 45, HCO3 26 c pH 7.35, CO2 40, HCO3 22 d pH 7.30, CO2 45, HCO3 18 ANS: D As shock progresses along the continuum, acidosis ensues, caused by metabolic acidosis, hypoxia, and anaerobic metabolism A pH 7.30, CO2 45 mm Hg, HCO3 18 indicates metabolic acidosis and progression to a late stage of shock All other listed arterial blood gas values are within normal limits DIF: Cognitive Level: Application REF: p 260 https://getbooksolutions.com OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk 29 The nurse is caring for a patient admitted following a motor vehicle crash Over the past hours, the patient has received units of packed red blood cells and units of fresh frozen plasma by rapid infusion To prevent complications, what is the priority nursing intervention? a Administer pain medication b Turn patient every hours c Assess core body temperature d Apply bilateral heel protectors ANS: C Hypothermia is anticipated during the rapid infusion of fluids or blood products Assessment of core body temperature is a priority While administration of pain management, repositioning the patient every hours, and application of heel protectors should be part of the patient care, given the rapid transfusion of blood products, these interventions are not the priority in this scenario DIF: Cognitive Level: Application REF: pp 267-268 https://getbooksolutions.com OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk 30 The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine (Dobutrex) The physician’s order calls for the nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m2 The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2 What is the best action by the nurse? a Obtain a stat serum potassium level b Order a stat 12-lead electrocardiogram c Reduce the rate of dobutamine (Dobutrex) d Assess the patient’s hourly urine output ANS: C Dobutamine (Dobutrex) is used to stimulate contractility and heart rate while causing vasodilation in low cardiac output states improving overall cardiac performance The patient’s cardiac index is well above normal limits, so the rate of infusion of the medication should be reduced so as not to overstimulate the heart There is no evidence to support the need for a serum potassium or 12-lead electrocardiogram Assessment of hourly urine output is important in the care of the patient in cardiogenic shock, but it is not a priority in this scenario https://getbooksolutions.com DIF: Cognitive Level: Analysis REF: p 265 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies 31 After receiving a handoff report from the night shift, the nurse completes the morning assessment of a patient with severe sepsis Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) mm Hg, and urine output of 10 mL for the past hour The nurse initiates which active physician order first? a Administer infusion of 500 mL 0.9% normal saline every hours as needed if the CVP is < mm Hg b Increase supplemental oxygen therapy to maintain SpO2greater than 94% c Administer 40 mg furosemide (Lasix) intravenous as needed if the urine output is less than 30 mL/hr d Administer acetaminophen (Tylenol) 650-mg suppository per rectum as needed to treat temperature > 101° F ANS: A https://getbooksolutions.com Fluid volume resuscitation is the priority in patients with severe sepsis to maintain circulating blood volume and end-organ perfusion and oxygenation A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient’s CVP of mm Hg and hourly urine output of 10 mL/hr There is no evidence to support the need to increase supplemental oxygen Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated DIF: Cognitive Level: Analysis REF: p 262 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 32 The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer solution over the past hours Morning laboratory results show a hemoglobin of g/dL and hematocrit of 28% What is the best interpretation of these findings by the nurse? a Blood transfusion with packed red blood cells is required b Hemoglobin and hematocrit results indicate hemodilution c Fluid resuscitation has resulted in fluid volume overload d Fluid resuscitation has resulted in third spacing of fluid https://getbooksolutions.com ANS: B Fluid resuscitation with large volumes of crystalloid results in hemodilution of red blood cells and plasma proteins Hemoglobin and hematocrit results indicate hemodilution Given the clinical scenario, there is no evidence to support the need for a blood transfusion and no evidence of fluid overload Although administration of large volumes of crystalloid can result in hemodilution of plasma proteins leading to third spacing of fluid, this fact does not support the hemoglobin and hematocrit results DIF: Cognitive Level: Comprehension REF: p 260 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Reduction of Risk MULTIPLE RESPONSE Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a drop in the patient’s blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102° F The nurse notes the new onset of hematuria in the patient’s Foley catheter What are the priority nursing actions? (Select all that apply.) a Administer acetaminophen (Tylenol) b Document the patient’s response https://getbooksolutions.com c Increase the rate of transfusion d Notify the blood bank e Notify the physician f Stop the transfusion ANS: B, D, E, F In the event of a reaction, the transfusion is stopped, the patient is assessed, and both the physician and laboratory are notified All transfusion equipment (bag, tubing, and remaining solutions) and any blood or urine specimens obtained are sent to the laboratory according to hospital policy The events of the reaction, interventions used, and patient response to treatment are documented Acetaminophen is not warranted in the immediate recognition and treatment of a transfusion reaction The infusion must be stopped Increasing the infusion further increases the likelihood of worsening the transfusion reaction DIF: Cognitive Level: Analysis REF: p 278 OBJ: Describe management strategies for each classification of shock TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity The nurse is caring for a young adult patient admitted with shock The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) https://getbooksolutions.com a Blood pressure b Heart rate c Level of consciousness d Pupil response e Respirations f Urine output ANS: A, C, F The level of consciousness assesses cerebral perfusion, urine output assesses renal perfusion, and blood pressure is a general indicator of systemic perfusion Heart rate is not an indicator of perfusion Pupillary response does not assess perfusion Respirations not assess perfusion DIF: Cognitive Level: Analysis REF: p 257 | Clinical Alert OBJ: Relate assessment findings to the classification and stage of shock TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity