The nurse assesses the client's IV infusion. Which clinical indicator cues the nurse to take special precautions while infusing IV fluids?
1. Poor skin turgor
2. Bilateral crackles
3. Mild hypotension
4. High serum sodium
2
2. The nurse scrutinizes IV therapy for clients with crackles in the lungs because it is consistent with clinical indicators of fluid overload and pulmonary edema. In fact, crackles consistently indicate fluid of some type in the lungs and are a classic sign of fluid overload. As a result, the nurse administers IV fluids to the client with heigh-tened scrutiny to avoid administering excess IV fluids.
1, 3, and 4. Poor skin turgor, hypernatremia, and hypotension indicate a potential need for additional fluid volume.
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