A nurse is caring for a client who has fluid volume excess. Which of the following actions should the nurse take? (Select all that apply.)

Choice A reason:

Increased skin turgor is not a sign of fluid volume deficit, but rather a sign of normal hydration. Skin turgor is the elasticity of the skin that allows it to return to its original shape after being pinched. Fluid volume deficit causes decreased skin turgor, which means the skin stays tented or takes longer to flatten after being pinched.

Choice B reason:

Hypertension is not a sign of fluid volume deficit, but rather a sign of fluid volume excess. Fluid volume deficit causes hypotension, which means low blood pressure. Fluid volume excess causes hypertension, which means high blood pressure. This is because fluid volume affects the amount of blood in the vessels and the pressure it exerts on the vessel walls.

Choice C reason:

Tachycardia is a sign of fluid volume deficit. Tachycardia means fast heart rate, usually more than 100 beats per minute. Fluid volume deficit causes tachycardia because the heart has to pump faster and harder to compensate for the low blood volume and maintain adequate blood flow to the vital organs.

Choice D reason:

Crackles in the lungs are not a sign of fluid volume deficit, but rather a sign of fluid volume excess or pulmonary edema. Crackles are abnormal lung sounds that indicate fluid accumulation in the alveoli or air sacs of the lungs. Fluid volume deficit does not cause fluid accumulation in the lungs, but rather dehydration of the lung tissues. Some additional information: Fluid volume deficit, also known as dehydration, is a condition where the body loses more fluids than it takes in. This can result from excessive vomiting, diarrhea, sweating, burns, hemorrhage, or diuretic use. Fluid volume excess, also known as overhydration or hypervolemia, is a condition where the body retains more fluids than it needs. This can result from excessive fluid intake, kidney failure, heart failure, liver cirrhosis, or steroid use. Fluid balance is essential for maintaining homeostasis and normal functioning of the body systems. Fluid balance is regulated by various mechanisms such as thirst, urine output, hormones, and electrolytes.

Choice A reason:

Monitoring daily weight is an important action for the nurse to take because it reflects the fluid status of the client. A sudden increase in weight indicates fluid retention, while a sudden decrease indicates fluid loss. The nurse should weigh the client at the same time every day, using the same scale and clothing.

Choice B reason:

Restricting sodium intake is another action that the nurse should take because sodium attracts water and increases fluid volume. The nurse should limit or avoid foods that are high in sodium, such as processed meats, canned soups, cheese, pickles, and salty snacks. The nurse should also educate the client about reading food labels and choosing low-sodium alternatives.

Choice C reason:

Administering diuretics as prescribed is a third action that the nurse should take because diuretics increase urine output and reduce fluid volume. The nurse should monitor the client's electrolyte levels, blood pressure, and urine output before and after giving diuretics. The nurse should also inform the client about the possible side effects of diuretics, such as dehydration, hypotension, hypokalemia, and ototoxicity.

Choice D reason:

Encouraging oral fluids is not an action that the nurse should take because it would worsen the fluid volume excess. The nurse should limit or restrict oral fluids as ordered by the provider. The nurse should also measure and record all fluid intake and output accurately.

Choice E reason:

Elevating the head of the bed is a fourth action that the nurse should take because it improves respiratory function and reduces pulmonary congestion. The nurse should elevate the head of the bed to at least 30 degrees or more, depending on the client's comfort and tolerance. The nurse should also monitor the client's oxygen saturation, breath sounds, and dyspnea.