A nurse is collecting data from an older adult who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (Select all that apply.).

Choice A rationale:

Hypoglycemia Hypokalemia (low potassium levels) is not typically associated with hypoglycemia (low blood sugar). Hypokalemia primarily affects the function of muscles and nerves, and it does not directly influence blood glucose levels.

Choice B rationale:

Cardiac dysrhythmias Hypokalemia can lead to cardiac dysrhythmias. Potassium plays a crucial role in maintaining the electrical activity of the heart, and low potassium levels can disrupt normal cardiac rhythms, potentially leading to life-threatening arrhythmias. Cardiac dysrhythmias are a well-recognized complication of severe hypokalemia, making this choice the correct one.

Choice C rationale:

Increased appetite Hypokalemia is not associated with an increased appetite. In fact, it can lead to gastrointestinal disturbances, such as nausea, vomiting, and abdominal pain, which may decrease appetite. The primary manifestations of hypokalemia are related to muscle weakness and cardiac abnormalities.

Choice D rationale:

Hyperreflexia Hyperreflexia (excessive reflex responses) is not a typical manifestation of hypokalemia. Hypokalemia is more commonly associated with muscle weakness, cramps, and cardiac disturbances. Hyperreflexia is often seen in conditions of excessive calcium levels (hypercalcemia) or neurological disorders, not hypokalemia.

Choice A rationale:

The nurse should prioritize collecting data from a client who reports unilateral calf pain when ambulating. This symptom could indicate the presence of a deep vein thrombosis (DVT), a potentially life-threatening condition. DVT occurs when a blood clot forms in a deep vein, often in the lower extremities. If left untreated, the clot can dislodge and travel to the lungs, causing a pulmonary embolism. Immediate assessment is crucial to rule out DVT and provide appropriate interventions. The nurse should assess the client's calf for swelling, redness, warmth, and tenderness and may also order diagnostic tests like a duplex ultrasound.

Choice B rationale:

Taking a telephone prescription for a client being transferred from the PACU is important but not the top priority in this situation. While timely transfer and adequate post-operative care are essential, addressing a client with unilateral calf pain and the potential for a DVT takes precedence due to the risk of a life-threatening complication.

Choice C rationale:

Reassuring the partner of a client who sustained a closed head injury is a compassionate action but should not be the first priority. The partner's emotional support can be provided once the immediate medical concerns have been addressed.

Choice D rationale:

Reinforcing a client's dressing on an above-the-knee amputation surgical site is important for the client's post-operative care, but it is not the highest priority when compared to the possibility of a DVT. The nurse should address the client's calf pain first and then attend to the dressing reinforcement.