A client has been admitted with a diagnosis of septic shock and has been successfully intubated. The nurse performs and documents a rapid assessment. Which information from the assessment requires the most immediate action by the nurse?
Vital Signs: Blood Pressure 92/54 mmHg, Heart Rate 116 bpm, Respiratory Rate 22 breaths/min, Temperature 103F (39.4C), Oxygen Saturation 91%.
Documentation: Heart tones irregular, distant. Face flushed and warm. Extremities cool and mottled. Radial pulses faintly palpable. Pedal pulses non-palpable. Denies chest pain. Endotracheal tube taped in place via oropharynx. Right anterior and posterior lung sounds clear. Unable to hear left lung sounds. Grimaces with light abdominal palpation over pelvic bone. Urine amber and cloudy with red streaks. 100 mL urine output in foley catheter bag. Opens eyes and moves to command. Pupils equal, round, and react to light.
1. Lung assessment finding
2. Blood pressure reading
3. Elevated temperature
4. Urine description and output