medium · NCLEX-RN basic-care
A nurse is caring for a client with an order for 0.9% sodium chloride at 100 mL/hour. The client has a history of heart failure.
Which finding most likely indicates that the client is successfully compensating for the fluid intake?
- New-onset S3 gallop heard upon heart auscultation.
- Urine output of 60 mL/hour and clear breath sounds.
- A central venous pressure (CVP) of 15 mm Hg (Reference: 2-8 mm Hg).
- A weight gain of 1 kg (2.2 lbs) over the past 24 hours.
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