Asked by Rodrigo Martin on May 02, 2024
Verified
While assessing the patient,the nurse recognizes that special caution should be taken with the intravenous (IV) infusion because of fluid volume excess when the nurse notes the presence of which condition?
A) Poor skin turgor
B) Crackles in the lungs
C) Decreased blood pressure
D) Dry skin and mucous membranes
Fluid Volume Excess
A condition characterized by an abnormal retention of water and sodium in the body leading to swelling and weight gain.
Crackles
Abnormal lung sounds heard through a stethoscope characterized by popping, clicking, rattling, or bubbling sounds, indicating fluid in the airways.
- Recognize signs of fluid overload and appropriate nursing interventions.
Verified Answer
RG
Rafael GuzmanMay 04, 2024
Final Answer :
B
Explanation :
Auscultation of crackles or rhonchi in the lungs may signal fluid buildup in the lungs caused by fluid volume excess.Poor skin turgor is common with fluid volume deficit.The pinched skin stays elevated for several seconds (tenting).This may be an indication of the need for IV therapy.Decreased blood pressure may indicate fluid volume deficit caused by a decrease in stroke volume.This may indicate the need for intravenous (IV)therapy.Dry skin and mucous membranes may indicate dehydration.
Learning Objectives
- Recognize signs of fluid overload and appropriate nursing interventions.
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