The client has been receiving intravenous (IV) fluids for the last 6 hours and now is demonstrating bounding pulse, crackles in the lungs, leg swelling, and a blood pressure more than 15 mm Hg higher than baseline
Which is the most likely nursing diagnosis for this client? A) Ineffective Peripheral Tissue Perfusion
B) Ineffective Airway Clearance
C) Excess Fluid Volume
D) Impaired Tissue Integrity
C
Feedback:
The symptoms the client is experiencing indicated excess fluid volume. If the edema continues in the lower extremities, peripheral tissue perfusion and integrity can become impaired. Ineffective airway associated with the crackles is directly related to the fluid volume overload.
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