A nurse is discussing early signs of hypervolemia with a patient admitted with congestive heart failure. Which signs should the nurse include in their teaching?

Choice A reason: Securing the drain to the client's bed sheet is not the best action for the nurse to take. This could cause the drain to be pulled or dislodged if the client moves or changes position. The nurse should secure the drain to the client's gown or abdominal binder, using a safety pin or a clip.

Choice B reason: Removing the JP drain when the drainage has ceased, covering the opening with sterile gauze, is not the correct action for the nurse to take. The nurse should not remove the drain without a physician's order, as this could cause complications such as infection, bleeding, or bile leakage. The nurse should monitor the amount and color of the drainage, and report any changes to the physician.

Choice C reason: Expelling the air from the JP bulb after emptying to re-establish suction is the correct action for the nurse to take. The JP drain works by creating a negative pressure that draws fluid from the surgical site. The nurse should empty the bulb when it is half full, and squeeze it until it collapses before closing the plug. This ensures that the suction is maintained and prevents the fluid from flowing back into the drain.

Choice D reason: Measuring the drainage every hour for the first 8 hr postoperative is not the correct action for the nurse to take. This is too frequent and unnecessary, as the drainage is expected to decrease over time. The nurse should measure the drainage every 8 to 12 hr, or as ordered by the physician, and record the volume and color. The nurse should also report any signs of infection, such as fever, pain, or foul odor.

Choice A reason: Decreased heart rate is not a manifestation of hypovolemia. Hypovolemia is a condition where there is a decreased volume of blood in the body, which can result from blood loss, dehydration, or fluid shifts. Hypovolemia can cause the heart rate to increase, not decrease, as the body tries to compensate for the low blood pressure and maintain adequate perfusion.

Choice B reason: Increased blood pressure is not a manifestation of hypovolemia. Hypovolemia can cause the blood pressure to decrease, not increase, as the blood volume and cardiac output are reduced. The body may try to constrict the blood vessels to increase the blood pressure, but this is usually not enough to overcome the effects of hypovolemia.

Choice C reason: Weak pulse is a manifestation of hypovolemia. Hypovolemia can cause the pulse to become weak, thready, or difficult to palpate, as the blood flow and pressure are diminished. The pulse may also become irregular or rapid, as the heart tries to pump faster and harder to deliver oxygen to the tissues.

Choice D reason: Dyspnea is not a specific manifestation of hypovolemia. Dyspnea is a term for difficulty breathing, which can have many causes, such as asthma, pneumonia, or pulmonary edema. Hypovolemia can cause dyspnea if it leads to shock, which is a life-threatening condition where the organs and tissues are not receiving enough oxygen. However, dyspnea alone is not enough to indicate hypovolemia.