A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?
Explanation & Rationale
A. Weight loss: Fluid overload is characterized by excessive fluid retention rather than loss. Weight gain is a more common finding due to fluid accumulation in tissues. Weight loss would be associated with dehydration, malnutrition, or inadequate caloric intake rather than fluid overload. B. Decreased blood pressure: Fluid overload typically leads to increased blood pressure due to excess circulating volume. Decreased blood pressure is more commonly seen in dehydration or conditions that result in significant fluid loss, such as hemorrhage or severe diarrhea. C. Decreased skin turgor: Poor skin turgor is a sign of dehydration rather than fluid overload. In fluid overload, clients may exhibit edema, moist skin, and increased vascular volume instead of signs of dehydration. D. Crackles heard in the lungs: Crackles in the lungs indicate pulmonary congestion due to excess fluid accumulation, which can occur with fluid overload. Increased intravascular volume leads to leakage of fluid into the alveoli, causing difficulty breathing, shortness of breath, and pulmonary edema in severe cases.