A patient with a history of cardiac dysrhythmias is admitted with fluid volume deficit due to a pulmonary infection. The nurse records several vital signs. Which sign requires reassessment?

A patient with a history of cardiac dysrhythmias is admitted with fluid volume deficit due to a pulmonary infection. The nurse records several vital signs. Which sign requires reassessment?

• A. Respiratory rate of 14
• B. BP 120/80
• C. O2 saturation 95%
• D. Pulse rate 88

Answer: (A)

The main idea here is that respiratory status is often the first indicator of how well a patient with a pulmonary infection and fluid volume deficit is tolerating the illness. In dehydration from a pulmonary infection, the body typically increases breathing effort to improve oxygen delivery and CO2 removal, so you’d expect the respiratory rate to be elevated rather than staying at the normal range. A respiratory rate of 14 is within the normal range, which is not what you’d anticipate given the diagnosis and the physiologic stresses from infection and fluid loss. That mismatch means you should reassess this measurement to confirm accuracy (count for a full minute, ensure the patient is at rest) and to watch for any developing respiratory distress or fatigue. The other signs—blood pressure, oxygen saturation, and pulse rate—are currently within acceptable values and don’t by themselves indicate immediate concern, though they should continue to be monitored.

The main idea here is that respiratory status is often the first indicator of how well a patient with a pulmonary infection and fluid volume deficit is tolerating the illness. In dehydration from a pulmonary infection, the body typically increases breathing effort to improve oxygen delivery and CO2 removal, so you’d expect the respiratory rate to be elevated rather than staying at the normal range.

A respiratory rate of 14 is within the normal range, which is not what you’d anticipate given the diagnosis and the physiologic stresses from infection and fluid loss. That mismatch means you should reassess this measurement to confirm accuracy (count for a full minute, ensure the patient is at rest) and to watch for any developing respiratory distress or fatigue. The other signs—blood pressure, oxygen saturation, and pulse rate—are currently within acceptable values and don’t by themselves indicate immediate concern, though they should continue to be monitored.