Which assessment finding should cause a nurse to question administering a sodium-containing isotonic intravenous fluid?
a. Blood pressure 102/58
b. Dry mucous membranes
c. Poor skin turgor
d. Pitting edema
ANS: D
Pitting edema indicates that the patient may be retaining excess extracellular fluid, and the nurse should question the type of solution meant to rehydrate the patient. All other options are con-sistent with ECV deficit, and the patient would benefit from a sodium-containing isotonic solu-tion that expands extracellular volume.
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