Which assessment findings indicate to the nurse that a child has excess fluid volume? Select all that apply
a. Weight gain
b. Decreased blood pressure
c. Moist breath sounds
d. Poor skin turgor
e. Rapid bounding pulse
A, C, E
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Correct A child with fluid volume excess will have a weight gain, moist breath
sounds due to the excess fluid in the pulmonary system, and a rapid
bounding pulse. Other signs seen with fluid volume excess are increased
blood pressure, edema, and fatigue.
Incorrect Decreased blood pressure and poor skin turgor are signs of fluid volume
deficit.
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