While assessing the patient, the nurse recognizes that special caution should be taken with the IV infusion because of fluid volume excess when the nurse notes the presence of which condition?
a. Poor skin turgor
b. Crackles in the lungs
c. Decreased blood pressure
d. Dry skin and mucous membranes
B
Auscultation of crackles or rhonchi in the lungs may signal fluid buildup in the lungs caused by fluid volume excess. Poor skin turgor is common with fluid volume deficit. The pinched skin stays elevated for several seconds (tenting). This may be an indication of the need for IV therapy. Decreased blood pressure may indicate fluid volume deficit caused by a decrease in stroke volume. This may indicate the need for IV therapy. Dry skin and mucous membranes may indicate dehydration.
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