The nurse identifies the diagnosis Fluid Volume Overload as appropriate for a patient with heart failure. Which collected data should the nurse use to provide evidence for this diagnosis?
a. Skin warm to the touch
b. Oriented to person only
c. Respiratory rate 20 and shallow
d. +3 pitting edema of both feet and ankles
ANS: D
D. Collected data that the nurse should use as evidence for the diagnosis are signs and symptoms related to the diagnosis. For Fluid Volume Overload, edema would be used as evidence that the patient's tissue is accumulating extra fluid. A. Skin warm to the touch is an opinion. B. Oriented to person only is objective data; however, it does not apply to the nursing diagnosis. C. Respiratory rate 20 and shallow is objective data; however, it does not apply to the nursing diagnosis.
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