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    PN Comprehensive Predictor 2023 Proctored Exam

    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: Weight loss is more commonly associated with dehydration or inadequate nutritional intake. In fluid overload, clients typically demonstrate weight gain due to excess fluid retention. B. Decreased skin turgor: Decreased skin turgor is a sign of fluid volume deficit rather than excess. Fluid overload usually presents with edema and taut skin rather than reduced elasticity. C. Crackles heard in the lungs: Crackles indicate fluid accumulation in the alveoli and are a classic sign of fluid overload. This finding suggests pulmonary congestion and requires prompt assessment and intervention. D. Decreased blood pressure: Fluid overload is more likely to cause increased or normal blood pressure due to expanded intravascular volume. Decreased blood pressure is more consistent with hypovolemia or shock states.

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