NCLEX-PN® ExaminationPhysiological AdaptationHard
A client is admitted with a severe gastrointestinal bleed, and the nurse suspects hypovolemic shock. Which of the following assessment findings would be the PRIORITY to report to the healthcare provider?
- AHeart rate 118 beats/min
- BRespiratory rate 22 breaths/min
- CUrine output 20 mL/hour
- DBlood pressure 90/60 mmHg
Show answer & explanationAnswer & explanation
Correct answer: C. Urine output 20 mL/hour
While all options are concerning for hypovolemic shock, a urine output of 20 mL/hour (less than 0.5 mL/kg/hour for most adults) indicates significant renal hypoperfusion and impending acute kidney injury secondary to severe hypovolemia. This is a critical indicator of end-organ damage and a priority for intervention to prevent irreversible damage.
Why the other options are wrong
- A. Tachycardia (HR 118 bpm) is an early compensatory mechanism in shock, but not as immediate an indicator of organ damage as urine output.
- B. Tachypnea (RR 22 bpm) is a compensatory mechanism to acidosis or hypoxemia, but not as directly indicative of organ damage as severely decreased urine output.
- D. Hypotension (BP 90/60 mmHg) is a sign of shock, but specific organ perfusion (like kidneys) is a more direct indicator of severity.
Hypovolemic Shock Priority Assessment
In hypovolemic shock, inadequate tissue perfusion leads to organ dysfunction. Severely decreased urine output (<0.5 mL/kg/hr) is a critical indicator of renal hypoperfusion and impending acute kidney injury, requiring immediate intervention.
- Low urine output signals renal hypoperfusion.
- Early detection prevents irreversible organ damage.
- Other signs: hypotension, tachycardia, altered mental status.
Memory trick: Vital Signs: Urine Output is the Ultimate Organ Damage Signal