The nurse is caring for a postoperative client who has lost a significant amount of blood because of complications during a surgical procedure. Which of the following assessment findings would be indicative of further fluid volume deficit?
1. Pulse rate increases from 100 beats/min to 136 beats/min
2. +4 edema noted in lower extremities
3. Blood pressure rises from 116/68 to118/74 mm Hg
4. Crackles auscultated from lung bases to apices
1
Rationale: The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. An increase in the pulse rate compensates for decreases in fluid volume. "+4 edema noted in lower extremities" and "crackles auscultated from lung bases to apices" may be noted in fluid overload. A low blood pressure is expected in a postoperative client who lost a significant amount of blood.
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