An older adult patient has an intravenous infusion of 0.45% normal saline infusing at 150 mL/hr. The nurse is most concerned by which of the following assessment findings?
a. Tenderness at the IV site
b. Urine specific gravity is 1.018
c. Capillary refill is < 3 seconds
d. Newly noted crackles in the lungs
ANS: D
This patient is at risk for fluid volume overload; newly noted crackles are indicative of fluid volume overload. Other symptoms include a bounding pulse; respirations that are increased and shallow; distended neck veins; pitting edema in the feet and legs; urine specific gravity is low as the output of pale, dilute urine is increased. Tenderness at the IV site is concerning but is not the highest priority listed. The values listed for urine specific gravity and capillary refill are normal.
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