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    Ati lpn med surg proctored exam (perfusion)
    Select All That Apply

    A nurse is collecting data from an older adult who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (Select all that apply.)

    Explanation & Rationale

    A. Complaints of incisional pain: Not specific to fluid volume overload - more likely related to surgical wound/inflammation. B. Crackles in bilateral bases of lungs: Pulmonary crackles indicate fluid in the alveoli/airways from volume overload/ pulmonary edema. C. Distention of neck veins when supine: Jugular venous distention reflects increased central venous pressure seen with fluid overload/heart failure. D. Weight loss: Fluid volume overload causes weight gain, not weight loss. E. Swelling at the IV site: Not a reliable sign of systemic fluid volume overload - local swelling at an IV site more often indicates infiltration, phlebitis, or local edema rather than generalized intravascular volume overload.

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