A nurse is assessing an older adult client who is receiving 2 units of packed RBCs. Which of the following manifestations should indicate to the nurse that the client is experiencing circulatory overload?

Rationale:
A. Administer vasopressin to the client: Vasopressin helps control variceal bleeding by constricting splanchnic blood vessels. However, it cannot be safely or effectively administered until reliable IV access is confirmed, making it a secondary priority.

B. Request blood from blood bank: While the client may need transfusions to correct hypovolemia and blood loss, requesting blood is not the most immediate step. Before transfusion or medication, the nurse must ensure a functional IV line is available.

C. Verify that the client has adequate IV access: The priority in any hemorrhagic shock situation is to secure IV access to allow for fluid resuscitation, medication administration, and blood transfusion. Without IV access, no other interventions can be effectively implemented.

D. Insert an indwelling urinary catheter: Monitoring urine output is important in assessing renal perfusion and fluid status. However, this action does not address the immediate circulatory needs of the client and can be done after resuscitative access is secured.

Rationale:

• Temperature 37° C (98.6° F): The client's temperature has remained stable at 37° C from Day 1 to Day 3. Although it is within normal range, the lack of change means it does not reflect any clinical improvement or deterioration in condition.
• Blood pressure 112/56 mm Hg: The systolic blood pressure has improved from 92 mm Hg to 112 mm Hg, suggesting improved perfusion. Although diastolic pressure is unchanged, this rise indicates partial stabilization of cardiovascular status after initial hypotension.
• Heart rate 88/min: The heart rate decreased from 118/min on Day 1 to 88/min on Day 3, indicating reduced sympathetic response. This suggests that blood volume and hemodynamic status have improved, likely due to effective intervention for blood loss.
• Respiratory rate 20/min: A drop from 24/min to 20/min reflects improvement in respiratory effort. The normalization of respiratory rate indicates reduced metabolic demand and improved oxygen delivery after stabilization.
• Oxygen saturation 95% on room air: The client’s oxygen saturation improved from 92% to 95%, returning to normal range. This shows better oxygenation, likely related to improved circulatory status and reduced bleeding or hypovolemia.
• Hemoglobin 15 g/dL: Hemoglobin increased from 7 g/dL to 15 g/dL, returning to normal. This significant rise indicates successful treatment of anemia, likely through blood transfusion, and improved oxygen-carrying capacity.
• Hematocrit 45%: Hematocrit rose from 24% to 45%, matching the hemoglobin improvement. This suggests the client’s volume status and red blood cell concentration have normalized, reflecting effective management of acute blood loss.
• Platelets 100,000/mm³: The platelet count decreased from 120,000/mm³ to 100,000/mm³, remaining below the normal range. This decline may reflect worsening liver dysfunction or ongoing coagulopathy, and does not indicate clinical improvement.
• Albumin 3.0 g/dL: Albumin remained unchanged at 3.0 g/dL and is below the normal range of 3.5–5 g/dL. This reflects persistent impaired liver synthetic function and ongoing risk for complications like ascites and delayed healing.
• Ammonia 160 mcg/dL: Ammonia levels increased from 150 to 160 mcg/dL, indicating worsening hepatic detoxification. This elevated level increases the client’s risk for hepatic encephalopathy and does not signify recovery.