Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph
A nurse is evaluating a client who received intermittent IV fluids. Which of the following findings indicates the client has a fluid overload?
Explanation & Rationale
A. Tenting of the skin suggests dehydration, not fluid overload. B. A respiratory rate of 30/min indicates tachypnea, which can occur due to pulmonary congestion and decreased gas exchange from fluid overload. Other signs may include crackles, dyspnea, elevated blood pressure, and jugular vein distension. C. A heart rate of 60/min is normal; fluid overload typically causes tachycardia as the body compensates for increased volume and decreased oxygenation. D. Warm, dry skin is a normal finding and does not indicate excess fluid volume.
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