A nurse is evaluating a client for response to treatment for dehydration. Which finding indicates adequate response to isotonic fluids?

Choice A reason: Air embolism occurs when air enters the bloodstream, not from vesicant extravasation. Vesicants, like chemotherapy drugs, cause local tissue damage when leaking outside the vein, leading to necrosis, not vascular occlusion, making air embolism an incorrect complication in this context.

Choice B reason: Tissue necrosis is a primary complication of vesicant extravasation, as these medications (e.g., chemotherapy agents) are toxic to tissues outside the vein. Leakage causes severe damage, leading to cell death, ulceration, and potential tissue loss, making this the critical complication to identify and manage.

Choice C reason: Edema may occur with extravasation due to fluid leakage but is not the primary concern with vesicants. Vesicant extravasation causes severe tissue damage, leading to necrosis rather than just swelling, making edema a less specific and severe complication in this scenario.

Choice D reason: Thrombus formation is a risk with intravenous catheters but not a direct result of vesicant extravasation. Vesicants cause chemical damage to tissues, leading to necrosis, not clot formation, making thrombus an incorrect choice for vesicant extravasation’s primary effect.

Choice A reason: Fever and tachycardia indicate systemic inflammation in atelectasis, where collapsed alveoli reduce gas exchange, causing hypoxia. Tachycardia compensates for low oxygen, while cytokines from lung collapse trigger fever. These signs necessitate intervention like incentive spirometry to re-expand lungs, preventing complications such as pneumonia or sepsis, which worsen respiratory distress.

Choice B reason: Productive cough with green sputum suggests a bacterial infection, like pneumonia, rather than atelectasis alone. Atelectasis may predispose to infection by impairing mucociliary clearance, but green sputum indicates a secondary process requiring antibiotics, not primary atelectasis interventions like lung re-expansion, making this choice less urgent.

Choice C reason: Chest pain and increased respiratory rate are critical atelectasis symptoms. Pain arises from pleural irritation due to collapsed lung segments, while tachypnea compensates for hypoxia from reduced alveolar ventilation. These indicate significant respiratory compromise, requiring urgent interventions like chest physiotherapy or deep breathing to restore lung volume.

Choice D reason: Diminished breath sounds and dyspnea are hallmark atelectasis signs, reflecting collapsed alveoli and reduced air entry. Dyspnea results from impaired gas exchange, causing hypoxia and hypercapnia. Immediate interventions like positive pressure ventilation or incentive spirometry are needed to re-expand lungs, preventing further respiratory deterioration and ensuring adequate oxygenation.

Choice E reason: Purulent drainage is not typical of atelectasis but suggests an infectious process like an abscess or empyema. While atelectasis can trap secretions, predisposing to infection, purulent drainage requires specific treatments like antibiotics or drainage, not atelectasis-focused interventions like lung re-expansion, making this an incorrect choice for intervention.