The client in hypovolemic shock is receiving dextran, a non-blood colloid. Which assessment data would warrant immediate intervention by the nurse?

The client in hypovolemic shock is receiving dextran, a non-blood colloid. Which assessment data would warrant immediate intervention by the nurse?

• A. The client has a negative Chvostek sign.
• B. The client's pulse oximeter reading is 95%.
• C. The client refuses to cough and deep-breathe.
• D. The client has bilateral jugular vein distention (JVD).

Answer: (D)

When treating hypovolemic shock with a colloid like dextran, you expect the patient’s intravascular volume to be restored without signs of fluid overload. Bilateral jugular venous distention indicates elevated central venous pressure, which is not compatible with hypovolemia and suggests the patient is experiencing fluid overload or impaired venous return (cardiac or obstructive process). This finding signals an urgent problem: continuing the infusion could worsen pulmonary edema and respiratory distress. Therefore, the immediate action is to stop the dextran infusion and reassess the patient’s cardiovascular and respiratory status, notify the provider, and monitor for signs of fluid overload (crackles, edema, increased work of breathing) while preparing appropriate management.

When treating hypovolemic shock with a colloid like dextran, you expect the patient’s intravascular volume to be restored without signs of fluid overload. Bilateral jugular venous distention indicates elevated central venous pressure, which is not compatible with hypovolemia and suggests the patient is experiencing fluid overload or impaired venous return (cardiac or obstructive process). This finding signals an urgent problem: continuing the infusion could worsen pulmonary edema and respiratory distress.

Therefore, the immediate action is to stop the dextran infusion and reassess the patient’s cardiovascular and respiratory status, notify the provider, and monitor for signs of fluid overload (crackles, edema, increased work of breathing) while preparing appropriate management.