The nurse is providing care to a patient being treating for fluid volume excess. Which of the following assessment findings indicates that treatment has been effective?
a. Respiratory rate 24/min
b. Blood pressure 132/80 mm Hg
c. Weight loss of 5 lb in 24 hours
d. Output 1,500 mL in 24 hours
ANS: C
Weight is the most reliable measure of fluid volume. The respiratory rate is slightly elevated, which can be a sign of fluid excess. The blood pressure is unremarkable. Output of 1,500 mL may be normal and does not necessarily indicate resolution of fluid excess.
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