A patient with heart failure has BP 120/60, HR 64, R 18, T 97.6°F, coarse crackles bilaterally, and 3+ edema to the lower extremities. An appropriate nursing diagnosis for this patient is:
a. Impaired gas exchange
b. Excess Fluid Volume
c. Ineffective Tissue Perfusion
d. Deficient Knowledge
B
Excess Fluid Volume is an appropriate nursing diagnosis for someone demonstrating increased isotonic fluid retention, as demonstrated by adventitious breath sounds (crackles bilaterally) and edema. There is no indication that this patient is experiencing impaired gas exchange or inefficient tissue perfusion based on the information provided. Although the patient may have knowledge deficit, this is not a priority at this time.
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