A student nurse is discussing fluid overload with the staff nurse. Which statement by the student nurse indicates a need for further explanation by the staff nurse?
“Pitting edema is the best indicator of fluid overload.”
“The client may have distended veins in the hands and neck.”
“I may hear moist crackles in the lungs during my respiratory assessment.”
“The client may need drug therapy and sodium restriction to treat the overload.”
Number 1 is correct.
Rationale: Rapid weight gain is the best indicator of fluid excess, because visible signs of fluid overload may not be present. Fluid overload often results in distended veins in the hands and neck and moist crackles in the lungs. A combination of diuretics and nutrition therapy, including fluid and sodium restrictions, is the treatment for fluid overload.
