A nurse is collecting data on a client who has urinary retention. Which of the following findings should the nurse expect?

Choice A reason: Tachycardia is a sign of circulatory overload. Circulatory overload is a condition where the blood volume or rate of infusion is too high for the client's cardiovascular system. This causes the heart to beat faster and harder to pump the excess fluid, resulting in a high heart rate, or tachycardia.

Choice B reason: Weight loss is not a sign of circulatory overload. Weight loss is a condition where the body loses more calories than it consumes, resulting in a decrease in body mass. Weight loss can be caused by various factors, such as diet, exercise, illness, or medication. Weight gain, not weight loss, is a sign of circulatory overload, as the excess fluid accumulates in the body.

Choice C reason: Hypotension is not a sign of circulatory overload. Hypotension is a condition where the blood pressure is too low, which can impair the blood flow to the vital organs. Hypotension can be caused by various factors, such as dehydration, bleeding, shock, or medication. Hypertension, not hypotension, is a sign of circulatory overload, as the excess fluid increases the pressure in the blood vessels.

Choice D reason: Diaphoresis is not a sign of circulatory overload. Diaphoresis is a condition where the body sweats excessively, which can help to regulate the body temperature and eliminate toxins. Diaphoresis can be caused by various factors, such as fever, anxiety, exercise, or medication. Edema, not diaphoresis, is a sign of circulatory overload, as the excess fluid leaks into the interstitial spaces and causes swelling.

Choice A reason: Planning to administer insulin to the client is not a relevant action for the nurse to take, as it has no effect on respiratory alkalosis or hyperventilation. Insulin is used to lower blood glucose levels in patients with diabetes or hyperglycemia.

Choice B reason: Having the client breathe into a paper bag is a correct action for the nurse to take, as it helps to increase the carbon dioxide level in the blood and correct the alkalosis. Breathing into a paper bag creates a closed system that recycles the exhaled carbon dioxide and reduces the loss of carbon dioxide from the lungs.

Choice C reason: Planning to administer sodium bicarbonate to the client is not a correct action for the nurse to take, as it can worsen the alkalosis. Sodium bicarbonate is an alkali that can raise the pH of the blood and cause metabolic alkalosis. It is used to treat metabolic acidosis, not respiratory alkalosis.

Choice D reason: Having the client place their head between their knees is not a recommended action for the nurse to take, as it can impair the blood flow to the brain and cause fainting. It can also increase the respiratory rate and decrease the carbon dioxide level in the blood.