Question

The nurse realizes that a patient is experiencing a “warm and wet” acute decompensation when which of the following is noted:

a. Capillary refill > 3 seconds

b. Coarse breath sounds

c. RR of 16 bpm

d. Cool, clammy extremities

e. Agitation

Answer 1

The nurse realizes that a patient is experiencing a “warm and wet” acute decompensation when which of the following is noted:

b. Coarse breath sounds

Rationale:

Step 1:

The patient is experiencing Acute decompensation of warm and wet. The term warm indicates adequate cardiac output. Whereas wet indicates fluid overload. So the patient has hypervolemia. The accumulation of fluid in the lungs results in coarse breath sounds while breathing. Thus the wet results in coarse breath sound. Hence option b is correct.

Step 2:

If it is cold that indicates hypoperfusion. Hypoperfusion leads to increased capillary refill time. The skin becomes cool, clammy extremities, Hence option a, d is incorrect. Respiratory rate of 16bpm is normal and patient agitated when he had shortness of breath and decreased cardiac output. Hence option c, d, and e also incorrect.