A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply)
Increased respiratory rate.
Increased heart rate
Increased blood pressure
Increased Hematocrit
Increased temperature
Correct Answer : A,B,C
Choice A: Increased Respiratory Rate
Fluid overload, also known as hypervolemia, can lead to an increased respiratory rate. This occurs because the excess fluid in the body can accumulate in the lungs, leading to pulmonary congestion and edema. As a result, the body attempts to compensate by increasing the respiratory rate to improve oxygenation and remove excess carbon dioxide. Normal respiratory rate for adults is typically between 12-20 breaths per minute. An increased respiratory rate above this range can indicate fluid overload.
Choice B: Increased Heart Rate
An increased heart rate, or tachycardia, is another common finding in clients with fluid overload. The heart has to work harder to pump the excess fluid throughout the body, leading to an increased heart rate. This is a compensatory mechanism to maintain adequate cardiac output and tissue perfusion. Normal resting heart rate for adults is between 60-100 beats per minute. A heart rate above this range can be indicative of fluid overload.
Choice C: Increased Blood Pressure
Fluid overload can also result in increased blood pressure, or hypertension. The excess fluid in the bloodstream increases the volume of blood that the heart has to pump, leading to higher pressure within the arteries. This can strain the cardiovascular system and lead to complications if not managed properly. Normal blood pressure is typically around 120/80 mmHg. Blood pressure readings consistently above this range can suggest fluid overload.
Choice D: Increased Hematocrit
Increased hematocrit is not typically associated with fluid overload. Hematocrit is the proportion of red blood cells in the blood. In cases of fluid overload, the hematocrit level is usually decreased due to the dilutional effect of the excess fluid. Therefore, this choice is incorrect.
Choice E: Increased Temperature
Increased temperature is not a common finding in fluid overload. Fever or elevated body temperature is more commonly associated with infections or inflammatory conditions. Fluid overload does not typically cause an increase in body temperature. Therefore, this choice is incorrect.
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Correct Answer is A
Explanation
Choice A: He is NPO until the speech-language pathologist performs a swallowing evaluation.
When a client is admitted with a stroke, especially one affecting the left side, there is a significant risk of dysphagia, or difficulty swallowing. This can lead to choking and aspiration, which can cause pneumonia and other complications. Therefore, it is crucial to keep the client NPO (nothing by mouth) until a speech-language pathologist can perform a thorough swallowing evaluation. This ensures that the client can safely swallow without the risk of aspiration. The speech-language pathologist will assess the client’s ability to swallow different textures and consistencies of food and liquids and provide recommendations for safe feeding.
Choice B: Be sure to sit him up when you are feeding him to make him feel more natural.
While sitting the client up during feeding is a good practice to reduce the risk of aspiration, it is not sufficient on its own for a client who has just had a stroke. Without a proper swallowing evaluation, feeding the client could still pose a significant risk. Therefore, this choice is not the most appropriate response.
Choice C: You may give him a full-liquid diet, but please avoid solid foods until he gets stronger.
A full-liquid diet might seem like a safer option, but it still poses a risk of aspiration if the client has dysphagia. Without a swallowing evaluation, it is not safe to assume that the client can handle even a full-liquid diet. Therefore, this choice is not appropriate.
Choice D: Just be sure to add some thickener in his liquids to prevent choking and aspiration.
Adding thickener to liquids can help some clients with dysphagia, but it is not a one-size-fits-all solution. The appropriate consistency of liquids should be determined by a speech-language pathologist after a swallowing evaluation. Therefore, this choice is not appropriate without a prior assessment.
Correct Answer is A
Explanation
Choice A Reason:
Place the client on aspiration precautions: Myxedema coma is a severe form of hypothyroidism that can lead to decreased mental function and a reduced level of consciousness. These conditions increase the risk of aspiration, which can lead to pneumonia and other complications. Therefore, placing the client on aspiration precautions is crucial to prevent these risks. Aspiration precautions may include elevating the head of the bed, monitoring swallowing ability, and providing thickened liquids if necessary.
Choice B Reason:
Turn the client every 4 hours: While turning the client regularly is important to prevent pressure ulcers, it is not the primary action needed for a client in a myxedema coma. The focus should be on stabilizing the client’s condition and preventing life-threatening complications such as aspiration, respiratory failure, and cardiovascular collapse.
Choice C Reason:
Check the client’s blood pressure every 2 hours: Monitoring vital signs, including blood pressure, is essential for clients in a myxedema coma. However, it is not the most critical action compared to preventing aspiration. Blood pressure should be monitored regularly, but the frequency can be adjusted based on the client’s condition and stability.
Choice D Reason:
Initiate measures to cool the client: Clients in a myxedema coma typically present with hypothermia (low body temperature), not hyperthermia (high body temperature). Therefore, initiating measures to cool the client would be inappropriate and could worsen their condition. Instead, measures to warm the client, such as using blankets and adjusting room temperature, are more appropriate.
