A patient is in the intensive care unit with acute renal failure secondary to septic shock and is receiving IV fluids of 0.9% NaCl at 125 mL/hr
The patient develops crackles in the lungs, distended neck veins, 1+ pitting edema in the feet, and a 4-pound weight gain from the previous day. What nursing diagnosis is most appropriate for this situation?
a. Excess fluid volume
b. Decreased cardiac output
c. Ineffective tissue perfusion: peripheral
d. Imbalanced nutrition: greater than body requirements
ANS: A
A. Crackles, distended neck veins, edema, and weight gain are signs of fluid excess. B. C. The patient may have decreased cardiac output and ineffective tissue perfusion, but the patient's symptoms are those of fluid excess. D. IV fluids of 0.9% do not supply nutrition.
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