The nurse suspects a patient receiving IV therapy is experiencing fluid overload. Which assessment should the nurse perform first?
a. Check the patient's weight.
b. Assess lung sounds for crackles.
c. Observe the patient's feet for edema.
d. Inspect the insertion site for infiltration.
ANS: B
B. Crackles result from excess fluid backing up into the lungs. Breathing is a priority. A. C. Weight and edema may also indicate fluid excess, but are not as important as breathing. D. Infiltration at the insertion site is unrelated to fluid balance.
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