Difficulty: Medium
Average Score: 73%
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 excess? (Select all that apply)
Correct answer
A,C,E
Rationale
Correct Answer: A, C, E
Rationale:
A: Bounding pulse is a sign of fluid excess due to increased volume in the circulatory system, causing forceful arterial pulsations.
C: Pitting edema occurs when fluid accumulates in the interstitial spaces, indicating an excess of fluid in the body.
E: Crackles upon auscultation suggest fluid accumulation in the lungs, a common sign of fluid excess.
Incorrect Choices:
B: Urine-specific gravity greater than 1.030 indicates concentrated urine, not fluid excess.
D: Swelling at the IV site is a local issue, not indicative of systemic fluid excess.
Rationale:
A: Bounding pulse is a sign of fluid excess due to increased volume in the circulatory system, causing forceful arterial pulsations.
C: Pitting edema occurs when fluid accumulates in the interstitial spaces, indicating an excess of fluid in the body.
E: Crackles upon auscultation suggest fluid accumulation in the lungs, a common sign of fluid excess.
Incorrect Choices:
B: Urine-specific gravity greater than 1.030 indicates concentrated urine, not fluid excess.
D: Swelling at the IV site is a local issue, not indicative of systemic fluid excess.