The patient is on daily weights and is receiving intravenous therapy. The nurse notices that the patient has gained 2 kg since the previous morning. What else would the nurse expect to observe? (Select all that apply.)
a. Dry skin and mucous membranes
b. Distended neck veins
c. Tenting of the skin
d. Crackles or rhonchi in the lungs
B, D
A change in body weight of 1 kg corresponds to 1 L of fluid retention or loss. Dry skin and mucous membranes suggest fluid volume deficit (FVD). Distended neck veins suggest fluid volume excess (FVE). Poor skin turgor is seen when after pinching, the skin fails to return to normal position within 3 seconds. With FVD, the pinched skin stays elevated for several seconds. This is called tenting. Auscultation of crackles or rhonchi in the lungs may signal fluid buildup in the lungs caused by FVE.
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