A nurse in the PACU is administering an IV fluid bolus to an unconscious patient whose urine output has been less than 10 mL per hour for the last 2 hours

Question

Which findings would indicate that this patient is having an adverse reaction to this treatment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient develops crackles in the bilateral lung bases.
2. The patient's respiratory rate and depth increases.
3. The patient's oxygen concentration rises.
4. The patient's urine output increases.
5. The patient's incisional pain increases.

Answer 1

1,2
Rationale 1: Crackles are an indicator of fluid overload. The patient is not tolerating the fluid bolus.
Rationale 2: The patient may respond with shortness of breath. In the unconscious patient, this may manifest as an increase in respiratory rate and depth.
Rationale 3: The adverse effect would be a decrease in oxygen concentration.
Rationale 4: This is the desired effect of a fluid bolus.
Rationale 5: Fluid volume status does not affect incisional pain.