Practice Question
A nurse is collecting data from a client who is being treated for hypovolemia due to nausea and vomiting. Which of the following findings should the nurse report to the provider?
Answer Choices:
Correct Answer:
Heart rate 120/min
Rationale:
🔶 Tachycardia is an early and important sign of worsening hypovolemia, as the body tries to compensate for decreased circulating volume.
🔶 A heart rate of 120/min is significantly elevated and suggests that volume status may still be compromised.
🔶 Persistent or worsening tachycardia can precede hypotension and shock, so it requires prompt reporting and intervention.
🔶 In the context of recent nausea and vomiting, this is a red flag that fluid replacement may be inadequate.
🔶 Therefore, the heart rate of 120/min is the most critical finding to report to the provider.
Urine output 240 mL in 8 hr
🔶 An output of 240 mL in 8 hr equals 30 mL/hr, which is at the lower limit of normal for adequate kidney perfusion.
🔶 While borderline, it still meets the minimal standard of ≥30 mL/hr, so it is not immediately alarming.
🔶 Continued monitoring is necessary, but it does not demand urgent reporting in the same way as a HR of 120/min.
🔶 If output drops below 30 mL/hr or trends down further, it would then become more concerning.
🔶 As given, this value alone does not indicate acute worsening.
Blood pressure 110/55 mm Hg
🔶 A BP of 110/55 mm Hg is within acceptable limits, especially if the client is awake and perfusing adequately.
🔶 The diastolic is slightly low, but not at a level typically associated with shock or severe hypotension.
🔶 In hypovolemia, we worry more when we see significant drops in systolic BP or narrowing pulse pressure, neither of which is dramatic here.
🔶 When compared to a HR of 120, the BP is relatively stable.
🔶 Therefore, this BP does not require the same urgency as the tachycardia.
Respiratory rate 14/min
🔶 A respiratory rate of 14/min is within the normal adult range (12–20/min).
🔶 There is no indication of respiratory distress, compensatory tachypnea, or metabolic acidosis from this value.
🔶 In hypovolemia, concerning findings would include increased RR, dyspnea, or signs of shock, none of which are present here.
🔶 As such, this RR suggests the respiratory status is currently stable.
🔶 It does not need to be reported as an abnormal or urgent finding.
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This question is from ATI PN Adult Medical Surgical Online Practice 2023 B which contains 87 questions.
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From Exam
ATI PN Adult Medical Surgical Online Practice 2023 B
87 Questions
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- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: Medical-Surgical
- Answer Choices: 4