PN Adult Medical Surgical Practice Exam

In a client being treated for hypovolemia due to vomiting, what finding should the nurse report?

1. Hemoglobin 15 g/dL

2. Blood pressure 110/55 mm Hg

3. Heart rate 120/min

4. Potassium 3.6 mEq/L

The correct answer is: Heart rate 120/min

In the context of a client with hypovolemia due to vomiting, a heart rate of 120 beats per minute is a significant finding that warrants reporting. This elevated heart rate, also known as tachycardia, is a common physiological response to hypovolemia as the body attempts to compensate for decreased blood volume and maintain adequate perfusion to vital organs. Tachycardia can indicate that the client is becoming more hemodynamically unstable and may be at risk for shock, especially if accompanied by other symptoms such as hypotension or signs of inadequate tissue perfusion. The other findings, while important to monitor, do not indicate immediate concern in the same way. A hemoglobin level of 15 g/dL is within normal limits and suggests that the client is not experiencing significant anemia. Blood pressure at 110/55 mm Hg shows a mildly low diastolic pressure, yet it may still be acceptable depending on the individual’s baseline and overall clinical picture. A potassium level of 3.6 mEq/L is also within the normal range, indicating that electrolyte levels are stable despite the vomiting. Thus, the heart rate is the primary finding that signals a need for further intervention or reassessment.