A patient, being treated for a gastrointestinal bleed, has the following assessment findings: temperature 97.2°F, blood pressure 99/70 mm Hg, heart rate 74 bpm, capillary refill of 3 seconds, and oxygen saturation 94%

Question

Four hours later the nurse identifies changes in the patient's condition. Which changes are associated with complications from management of the condition? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Temperature 98.2°F
2. Heart rate 98 bpm
3. Oxygen saturation 85%
4. Capillary refill of 2 seconds
5. Rales auscultated bilateral bases

Answer 1

2,3,5
Rationale 1: This temperature is within normal limits.
Rationale 2: Tachycardia is a manifestation of fluid overload.
Rationale 3: Oxygen desaturation is a manifestation of fluid overload.
Rationale 4: This capillary refill is within normal limits.
Rationale 5: Abnormal lung sounds is a manifestation of fluid overload.