A patient is in the intensive care unit with acute renal failure secondary to septic shock and is receiving intravenous fluids of 0.9% NaCl at 125 mL/hr
The patient develops crackles in the lungs, distended neck veins, 1+ pitting edema in the feet, and a 4-pound weight gain from the previous day. What nursing diagnosis is most appropriate to this situation?
a. Imbalanced nutrition: greater than body requirements
b. Excess fluid volume
c. Decreased cardiac output
d. Ineffective tissue perfusion: peripheral
ANS: B
Crackles, distended neck veins, edema, and weight gain are signs of fluid excess. 0.9% does not supply nutrition. The patient may have decreased cardiac output and ineffective tissue perfusion, but the defining characteristics of fluid excess are most clearly those of fluid excess.
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