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 B
Explanation
Choice A reason: Consuming a high-protein diet is not typically recommended for clients with hepatitis B. While protein is essential for overall health, excessive protein intake can put additional strain on the liver. Instead, a balanced diet with adequate carbohydrates, fruits, and vegetables is advised to support liver function.
Choice B reason: Resting frequently throughout the day is crucial for clients with hepatitis B. The liver is responsible for many vital functions, including detoxification, protein synthesis, and the production of biochemicals necessary for digestion. When the liver is inflamed or damaged, as in hepatitis B, it needs ample rest to recover and function properly.
Choice C reason: Clients with hepatitis B should not donate blood. Hepatitis B is a bloodborne virus, and donating blood can transmit the infection to others. Blood donation guidelines strictly prohibit individuals with hepatitis B from donating blood, regardless of the time elapsed since completing medication.
Choice D reason: Taking acetaminophen every 4 hours for discomfort is not advisable for clients with hepatitis B. Acetaminophen is metabolized by the liver, and excessive use can lead to liver damage. Clients with liver conditions should use acetaminophen sparingly and under medical supervision to avoid exacerbating liver damage.
Correct Answer is D
Explanation
Choice A Reason:
A rosebud-like stoma orifice is a normal finding for a newly created colostomy. This appearance indicates that the stoma is healthy and well-formed. The stoma should protrude slightly from the abdomen and have a pink or red color, similar to the inside of the mouth. This indicates good blood flow and proper healing. Therefore, a rosebud-like stoma orifice does not need to be reported to the provider.
Choice B Reason:
A stoma oozing red drainage can be concerning, but it is not uncommon for a new stoma to have some minor bleeding or oozing, especially in the immediate postoperative period. This can occur due to the delicate nature of the tissue and the recent surgical intervention. However, if the drainage is excessive or persistent, it should be monitored closely and reported if it does not improve. Minor oozing is generally expected and does not necessarily indicate a serious problem.
Choice C Reason:
A shiny, moist stoma is a normal finding and indicates that the stoma is healthy. The stoma should be moist and have a shiny appearance, similar to the inside of the mouth. This moisture is necessary for the proper function and health of the stoma. Therefore, a shiny, moist stoma does not need to be reported to the provider.
Choice D Reason:
A purplish-colored stoma is an abnormal finding and should be reported to the provider immediately. This discoloration can indicate compromised blood flow to the stoma, which can lead to tissue necrosis if not addressed promptly. A healthy stoma should be pink or red, indicating good blood circulation. Any deviation from this color, especially a purplish or dark color, is a sign of potential ischemia or other serious complications that require immediate medical attention.