The nurse is performing an assessment of a client diagnosed with excess fluid volume due to renal failure. Which of the following assessment data is the nurse likely to find?
A) Hypotension
B) Feeble pulse
C) Crackles
D) Drowsiness
C
Feedback:
Crackles are the most important sign found in excess fluid volume. The client has the nursing diagnosis of excess fluid volume. The signs of increased fluid volume are adventitious lung sounds, a bounding pulse, and high blood pressure; therefore, a diagnosis of hypotension or feeble pulse would be incorrect. Consciousness may become impaired at later stages when the fluid shift starts. The adventitious lung sounds indicate excess fluid volume.
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