A nurse is collecting data from a client who has fluid volume excess. Which of the following findings should the nurse expect?
Explanation & Rationale
Fluid volume excess occurs when there is an accumulation of isotonic fluid in the intravascular and interstitial spaces, often due to conditions such as heart failure, renal impairment, or excessive fluid intake. This leads to increased hydrostatic pressure and fluid shifting into tissues and body cavities. Respiratory and cardiovascular systems are commonly affected due to fluid overload. Nurses must recognize early signs of pulmonary congestion and systemic fluid retention to prevent complications such as pulmonary edema. Rationale: A. Weight loss is not expected in fluid volume excess; instead, clients typically experience rapid weight gain due to fluid retention. Daily weight monitoring is a key indicator of fluid status, and increases reflect worsening fluid overload rather than loss. B. Increased hematocrit is associated with fluid volume deficit because of hemoconcentration. In fluid volume excess, hematocrit is typically decreased due to dilution of blood components from excess plasma volume. Therefore, this finding is inconsistent with fluid overload. C. Crackles in the lungs are an expected finding in fluid volume excess due to accumulation of fluid in the alveolar spaces. This leads to impaired gas exchange and may progress to pulmonary edema. Crackles are typically heard on auscultation and indicate fluid shifting into the lungs. D. Weak peripheral pulses are more commonly associated with fluid volume deficit or poor perfusion states. In fluid volume excess, pulses are often bounding due to increased circulating volume and pressure. Therefore, weak pulses do not align with the expected findings of fluid overload.