A nurse is caring for a client who has fluid volume excess. Which of the following manifestations should the nurse expect?

Rationale for Correct Choices

• Oxygen saturation: The client’s oxygen saturation dropped from 95% to 90% on 1 L/min nasal cannula, indicating potential hypoxemia. Immediate assessment and intervention are required to prevent respiratory compromise.
• Behavioral findings: The client’s agitation and verbal report of “I feel like something is wrong” signal a possible early change in condition. Behavioral changes can precede vital sign abnormalities and should be promptly evaluated alongside physiological measures.

Rationale for Incorrect Choices

• Pain: While pain is reported at a moderate level, it is expected postoperatively and does not explain the sudden change in oxygen saturation or agitation. Pain should be addressed after assessing potential acute complications.
• WBC count: A slightly elevated WBC may reflect postoperative inflammation or infection but is not the immediate priority in the context of acute hypoxemia.
• Bowel findings: Hypoactive bowel sounds are typical after abdominal surgery due to anesthesia and are not an urgent concern compared with declining oxygenation and agitation.

Rationale

A. Speech therapy referral: Referral to speech therapy is appropriate for a client with dysphagia, as a speech-language pathologist can assess swallowing ability and provide strategies to reduce aspiration risk. This supports safe oral intake and rehabilitation.

B. Clear liquids: Prescribing a clear liquid diet may be unsafe for a client with dysphagia, particularly if the client has difficulty swallowing thin liquids, which can increase the risk of aspiration. The nurse should clarify this prescription and consider thickened liquids or alternative feeding methods based on the speech therapist’s assessment.

C. Oral suction at the bedside: Having oral suction available is appropriate for a client with dysphagia to quickly manage secretions or prevent choking and aspiration during oral intake. This intervention promotes safety.

D. Dietitian consult: Consulting a dietitian is appropriate to ensure the client receives adequate nutrition and a safe texture-modified diet. The dietitian can recommend consistency adjustments and nutrient-dense options tailored to the client’s swallowing abilities.