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    HESI RN Med surg proctored exam 3

    A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?

    Explanation & Rationale

    Choice A reason: Lung sounds are important to assess for signs of fluid in the lungs, such as crackles, which can occur with fluid volume overload. However, they do not directly measure fluid balance.Choice B reason: Turgor assesses skin elasticity and hydration status, but it is not the most accurate indicator of overall fluid balance in the context of fluid volume overload.Choice C reason: Weight is the most accurate and direct measure of fluid balance. Daily weight monitoring can track changes in fluid status, as weight fluctuations can reflect gains or losses in body fluid.Choice D reason: Blood pressure is important to monitor, especially in clients with fluid volume issues, but it is not the most direct measure of fluid balance. Weight changes provide more precise information about fluid status.

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