Orly Khan is suffering from fluid volume deficit (FVD), which of the following symptoms would the nurse expect to assess in the patient?
A. Rales
B. Bounding pulse
C. Tachycardia
D. Bulging neck veins
Correct Answer: C. Tachycardia
Tachycardia, poor tissue turgor, and hypotension are symptoms of FVD. Other choices are symptoms of FVE. A decrease in circulating blood volume can cause hypotension and tachycardia. Alteration in HR is a compensatory mechanism to maintain cardiac output.
Option A: Auscultate and document heart sounds; note rate, rhythm or other abnormal findings. Cardiac alterations like dysrhythmias may reflect hypovolemia and/or electrolyte imbalance, commonly hypocalcemia. Note: MI, pericarditis, and pericardial effusion with/ without tamponade are common cardiovascular complications.
Option B: Usually, the pulse is weak and may be irregular if electrolyte imbalance also occurs. Hypotension is evident in hypovolemia. Close monitoring for responses during therapy reduces complications associated with fluid replacement.
Option D: Assess skin turgor and oral mucous membranes for signs of dehydration. Signs of dehydration are also detected through the skin. Skin of elderly patients loses elasticity, hence skin turgor should be assessed over the sternum or on the inner thighs. Longitudinal furrows may be noted along the tongue.
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