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 C
Explanation
Choice A Reason:
Administering levetiracetam intravenously is not the first intervention. While levetiracetam is an antiepileptic drug used to control seizures, it is not the first-line treatment for an ongoing seizure, especially one lasting as long as 15 minutes. The priority in this situation is to stop the seizure activity immediately to prevent further complications, such as neuronal damage or status epilepticus. Levetiracetam may be used later for maintenance therapy, but it is not the initial emergency intervention.
Choice B Reason:
Obtaining a STAT electroencephalogram (EEG) is important for diagnosing and understanding the type of seizure activity, but it is not the first intervention. The immediate priority is to stop the seizure. An EEG can be performed after the seizure has been controlled to assess brain activity and guide further treatment. Delaying the administration of an anticonvulsant to perform an EEG could result in prolonged seizure activity and increased risk of complications.
Choice C Reason:
Administering lorazepam intravenously is the most appropriate first intervention. Lorazepam is a benzodiazepine that acts quickly to stop seizure activity. It is the drug of choice for treating status epilepticus and prolonged seizures because of its rapid onset and effectiveness. Administering lorazepam helps to quickly terminate the seizure, reducing the risk of complications and stabilizing the patient for further evaluation and treatment.
Choice D Reason:
Obtaining a STAT 12-lead electrocardiogram (ECG) is not the first intervention. While an ECG can provide valuable information about the patient’s cardiac status, it does not address the immediate need to stop the seizure. The priority is to administer an anticonvulsant to terminate the seizure. Once the seizure is controlled, an ECG can be performed to assess any potential cardiac issues, especially if the patient has a history of cardiac problems or if the seizure was triggered by a cardiac event.
Correct Answer is A
Explanation
Choice A reason:
Hypotension (low blood pressure), tachycardia (rapid heart rate), and lethargy are critical symptoms that can indicate a life-threatening condition such as shock or severe dehydration.Hypotension can lead to inadequate perfusion of vital organs, resulting in multi-organ failure if not promptly addressed1.Tachycardia is often a compensatory mechanism for hypotension, and lethargy indicates decreased cerebral perfusion.Immediate intervention is required to stabilize the patient’s condition and prevent further deterioration.
Choice B reason:
Dizziness with a headache rated 7/10 on the numeric scale is concerning but not immediately life-threatening.These symptoms could indicate a variety of conditions, such as migraine, vertigo, or even a mild concussion.While the patient should be assessed and treated, they do not present the same immediate risk as hypotension and tachycardia.
Choice C reason:
Abdominal pain, hypertension (high blood pressure), and constipation are symptoms that need medical attention but are not immediately life-threatening.Hypertension can lead to serious complications if left untreated, but it does not require the same urgent intervention as hypotension.Abdominal pain and constipation, while uncomfortable and potentially indicative of underlying issues, do not pose an immediate threat to life.
Choice D reason:
Febrile (fever), tachycardia, and vomiting are symptoms that suggest an infection or other acute illness.While these symptoms are concerning and need prompt evaluation, they do not pose the same immediate risk as hypotension and tachycardia.Fever and vomiting can lead to dehydration, but this typically develops over a longer period compared to the rapid deterioration seen with hypotension.