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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Choice A Reason:
Documenting that the nasogastric tube is in the correct place is not appropriate in this scenario. A gastric pH of 7.35 is too high for stomach contents, which typically have a pH between 1.5 and 3.5. This high pH suggests that the tube may be misplaced, possibly in the respiratory tract or another non-gastric location. Therefore, documenting the tube as correctly placed could lead to serious complications if the tube is indeed misplaced.
Choice B Reason:
Notifying the health care provider is the most appropriate action. A pH of 7.35 is indicative of a potential misplacement of the nasogastric tube. The health care provider needs to be informed immediately to take corrective actions, such as ordering an X-ray to confirm the tube’s placement or re-evaluating the tube’s position. This step is crucial to ensure patient safety and prevent complications such as aspiration pneumonia or other adverse effects.
Choice C Reason:
Checking for placement by auscultating for air injected into the tube is an outdated and unreliable method. This technique can sometimes give false assurance of correct placement, as the sound of air can be heard even if the tube is in the respiratory tract. Current best practices recommend using pH testing and radiographic confirmation for accurate placement verification.
Choice D Reason:
Retesting the pH using another strip might seem like a reasonable step, but it is not the best immediate action. If the initial pH test shows a value of 7.35, it is unlikely that retesting will yield a significantly different result. The priority should be to notify the health care provider to address the potential misplacement promptly.
Correct Answer is A
Explanation
Choice A Reason:
Activating the hospital’s emergency or rapid response system is the most appropriate first action in this scenario. The client is exhibiting signs of a potentially life-threatening condition, such as airway obstruction or severe swelling that could compromise breathing. Immediate intervention by a rapid response team can provide the necessary advanced airway management and other critical care measures to stabilize the patient. This action prioritizes the client’s airway, breathing, and circulation, which are the fundamental aspects of emergency care.
Choice B Reason:
Placing a heart monitor on the client and observing for dysrhythmias is important but not the immediate priority in this situation. While monitoring the heart is crucial, the client’s airway and breathing issues take precedence. Addressing the airway obstruction and ensuring adequate breathing should be the first step before focusing on cardiac monitoring.
Choice C Reason:
Asking the charge nurse to come see the client immediately is a reasonable action, but it may delay the necessary urgent intervention. The charge nurse may not have the advanced skills or equipment required to manage a severe airway obstruction. Activating the rapid response system ensures that a team of healthcare professionals with the appropriate expertise and equipment can respond quickly.
Choice D Reason:
Checking the client’s blood pressure and heart rate is a standard nursing assessment, but it is not the immediate priority in this emergency situation. The client’s difficulty breathing and stridor indicate a potential airway obstruction, which requires immediate attention. Ensuring the airway is clear and the client can breathe is more critical than checking vital signs at this moment.
Choice E Reason:
Providing a calm and assuring environment for the client is important for reducing anxiety and stress, but it does not address the immediate life-threatening issue. While maintaining a calm environment is beneficial, the nurse must first ensure that the client’s airway is secure and that they can breathe adequately. This can only be achieved by activating the rapid response system.