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colleen colleen
wrote...
Valued Member
Posts: 17076
11 years ago
A postoperative patient is diagnosed with fluid volume overload. Which of the following should the nurse assess in this patient?
1. poor skin turgor
2. decreased urine output
3. distended neck veins
4. concentrated hemoglobin and hematocrit levels
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Sunshine ☀ ☼

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wrote...
Valued Member
11 years ago
Correct Answer: 3
Rationale 1: Poor skin turgor is associated with fluid volume deficit.
Rationale 2: Decreased urine output is associated with fluid volume deficit.
Rationale 3: Circulatory overload causes manifestations such as a full, bounding pulse; distended neck and peripheral veins; increased central venous pressure; cough; dyspnea; orthopnea; rales in the lungs; pulmonary edema; polyuria; ascites; peripheral edema, or if severe, anasarca, in which dilution of plasma by excess fluid causes a decreased hematocrit and blood urea nitrogen (BUN); and possible cerebral edema.
Rationale 4: Increased hemoglobin and hematocrit values are associated with fluid volume deficit.
Global Rationale: Circulatory overload causes manifestations such as a full, bounding pulse; distended neck and peripheral veins; increased central venous pressure; cough; dyspnea; orthopnea; rales in the lungs; pulmonary edema; polyuria; ascites; peripheral edema, or if severe, anasarca, in which dilution of plasma by excess fluid causes a decreased hematocrit and blood urea nitrogen (BUN); and possible cerebral edema. The other answers indicate a fluid volume deficit.
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