The nurse is performing an assessment on a patient brought to the emergency department for treatment for dehydration
The nurse assesses a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5° C. The patient becomes dizzy when transferred from the wheelchair to a bed. The nurse notes cool, clammy skin. Which diagnosis does the nurse suspect?
a. Fluid volume deficit (FVD)
b. Fluid volume excess (FVE)
c. Mild extracellular fluid (ECF) deficit
d. Renal failure
ANS: A
Patients with FVD will exhibit elevated temperature, tachycardia, tachypnea, hypotension, orthostatic hypotension, and cool, clammy skin. Patients with FVE will have bounding pulses, elevated blood pressure, dyspnea, and crackles. Mild ECF deficit causes thirst. Renal failure generally leads to FVE.
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