A nurse is assessing a client who has circulatory overload. Which of the following findings should the nurse expect?

Diaphoresis

Weight loss

Hypotension

Tachycardia

Answer and Explanation

The Correct Answer is D

A) Diaphoresis:
While diaphoresis (excessive sweating) may occur with some cardiac or respiratory conditions, it is not a primary or expected sign of circulatory overload. Circulatory overload generally involves fluid accumulation in the body, and symptoms are more likely related to fluid retention and increased workload on the heart rather than sweating.

B) Weight loss:
Weight loss is not typically associated with circulatory overload. In fact, one of the hallmark signs of circulatory overload is weight gain due to fluid retention. The body retains excess fluid in the vascular system, leading to an increase in weight rather than weight loss.

C) Hypotension:
Hypotension (low blood pressure) is generally not associated with circulatory overload. Circulatory overload typically results in elevated blood pressure due to the increased volume of circulating fluid. In some cases, if the heart is unable to handle the increased volume, symptoms like pulmonary edema or shortness of breath can occur, but hypotension is more commonly seen in conditions like shock or severe fluid loss.

D) Tachycardia:
Tachycardia (an elevated heart rate) is a common finding in circulatory overload. When there is an excess of fluid in the body, the heart has to work harder to pump the additional volume of blood, leading to an increased heart rate. This is a compensatory response to the increased workload on the heart. It is also a sign that the body is attempting to maintain adequate tissue perfusion despite the excess fluid volume.

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Correct Answer is B

Explanation

A) The client is underweight:
Being underweight is not directly associated with an increased risk of incisional hematoma formation. However, underweight individuals may have a lower amount of subcutaneous fat, which could affect wound healing. While nutritional status plays a role in recovery after surgery, being underweight does not specifically increase the risk of hematoma formation at
the incision site.

B) The client takes anticoagulant medications:
Taking anticoagulant medications (e.g., warfarin, heparin, or newer anticoagulants like dabigatran) increases the risk of bleeding and the formation of an incisional hematoma. Anticoagulants work by reducing the blood's ability to clot, making it more difficult to stop bleeding after surgery. This increases the likelihood of blood accumulating in the tissue around the incision site, potentially forming a hematoma.

C) The client has urinary incontinence:
Urinary incontinence does not directly increase the risk of incisional hematoma formation. However, it can lead to other complications, such as skin irritation or infection, but it is not a primary risk factor for hematoma formation in the surgical wound. The main concern with urinary incontinence in the perioperative period is ensuring proper skin care to prevent moisture-associated skin damage.

D) The client has peripheral vascular disease:
Peripheral vascular disease (PVD) affects circulation in the extremities, which can impair wound healing due to decreased blood flow. While PVD can contribute to delayed healing and complications like infection, it is not the most significant factor for the formation of incisional hematomas.

A. Hypokalemia B. Bleeding C. Bradycardia D. Seizures

Correct Answer is C

Explanation

A) Hypokalemia:
Hypokalemia (low potassium levels) is not a common adverse effect of labetalol. While some medications, such as diuretics, can lead to hypokalemia, labetalol does not typically affect potassium levels directly. Instead, labetalol's primary effects are on blood pressure and heart rate.

B) Bleeding:
Bleeding is not a typical adverse effect of labetalol. Labetalol is a beta blocker that works by blocking beta-adrenergic receptors, which lowers heart rate and blood pressure. It does not interfere with blood clotting or platelet function, so bleeding would not be a concern unless the patient is on other medications that affect coagulation (such as anticoagulants).

C) Bradycardia:
Bradycardia, or a slow heart rate, is a well-known and common adverse effect of beta blockers like labetalol. Labetalol works by blocking the beta-1 adrenergic receptors in the heart, which can reduce heart rate and lower blood pressure. In some individuals, this can result in bradycardia, which could lead to symptoms like dizziness, fatigue, and fainting.

D) Seizures:
Seizures are not a typical adverse effect of labetalol. Although central nervous system effects like dizziness or fatigue can occur due to the blood pressure-lowering effects, seizures are not commonly associated with this medication.

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A nurse is assessing a client who has circulatory overload. Which of the following findings should the nurse expect?

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