Difficulty: Medium
Average Score: 82%
Simulated
A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply.)
Correct answer
A,D,E
Rationale
The correct answers are A, D, and E. Crackles upon auscultation indicate fluid volume excess in the lungs, as excess fluid accumulates in the alveoli causing crackling sounds. A bounding pulse is a sign of increased stroke volume and fluid overload. Pitting edema occurs due to fluid accumulation in the interstitial spaces. Choices B and C are incorrect as a urine-specific gravity greater than 1.030 indicates concentrated urine, not fluid volume excess, and swelling at the IV site may be due to local inflammation or extravasation, not necessarily fluid volume excess.