A nurse is collecting data for a client who is receiving enteral tube feeding. They should identify that which of the following findings is a manifestation of fluid overload?
Explanation & Rationale
A) Weight loss: Weight loss is not a sign of fluid overload; rather, it is more indicative of dehydration or insufficient nutritional intake. Fluid overload typically leads to weight gain due to the accumulation of excess fluid in the body, so weight loss would not be a manifestation of this condition. B) Decreased skin turgor: Decreased skin turgor is a common sign of dehydration, not fluid overload. When a person is dehydrated, the skin loses its elasticity, and it takes longer to return to its normal position after being pinched. This is the opposite of what is seen in fluid overload, where excess fluid causes the skin to appear more swollen or taut. C) Decreased blood pressure: Decreased blood pressure is more commonly associated with hypovolemia (low fluid volume) or dehydration, rather than fluid overload. In fluid overload, blood pressure may actually rise due to the increased volume of circulating blood, not decrease. D) Crackles heard in the lungs: Crackles, or rales, heard in the lungs are a classic sign of fluid overload, particularly when the excess fluid accumulates in the lungs (pulmonary edema). This can occur due to the heart's inability to pump effectively, leading to fluid retention in the lungs. Therefore, crackles in the lungs are a key manifestation of fluid overload.