Question

The nurse monitors the fluid status of an older patient receiving IV fluids following surgery. Which of the following symptoms suggests to the nurse that the patient has fluid volume overload?

1) Temperature 101°F (38.3°C), BP 96/60, pulse 96 and thready.
2) Cool skin, respiratory crackles, pulse 86 and bounding.
3) Complaints of a headache, abdominal pain, and lethargy.
4) Urinary output 700 ml/24 h, CVP of 5, and nystagmus.

Answer 1

Symptoms suggesting fluid volume overload in a patient include cool skin, respiratory crackles, and a bounding pulse. Hypervolemia is often caused by water and sodium retention and requires restoration of homeostasis to resolve.

Step-by-step explanation:

The symptoms suggesting that a patient has fluid volume overload, also known as hypervolemia, following surgery after receiving IV fluids include signs like cool skin, respiratory crackles, and a pulse that is strong or 'bounding'. Of the options provided, #2) Cool skin, respiratory crackles, pulse 86 and bounding indicates fluid volume overload. This condition is often caused by the retention of water and sodium, which may occur in diseases such as heart failure, liver cirrhosis, kidney disease, hyperaldosteronism, or due to certain steroid treatments. The restoration of homeostasis in patients with hypervolemia is critical and often involves reversing the condition that triggered the excessive fluid volume.