The nurse is caring for a patient who is being treating for fluid volume excess. Which assessment finding indicates that treatment has been effective?
a. Respiratory rate 24/min
b. Output 1500 mL in 24 hours
c. Blood pressure 132/80 mm Hg
d. Weight loss of 5 lb in 24 hours
ANS: D
D. Weight is the most reliable measure of fluid volume. A. The respiratory rate is slightly elevated, which can be a sign of fluid excess. B. Output of 1500 mL may be normal and does not necessarily indicate resolution of fluid excess. C. The blood pressure may be within the patient's normal limits.
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