What additional signs would the nurse expect to note in this client if the excess fluid volume is present?
The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume.
A. Weight loss B. Flat neck and hand veins C. An increase in blood pressure D. A decreased central venous pressure (CVP)
The nurse suspects that there is excess fluid volume so the best way to check that is through letter C. The nurse should look for an increase in blood pressure. There are different symptoms that will signify if there is excess fluid volume and an increase in blood pressure is one of them.
The other signs and symptoms to watch out for are a cough, dyspnea, tachycardia, bounding pulse, edema, and so much more. The other choices available are not related to checking if there is an excess in fluid volume so they can be eliminated from the choices that are available. It is best that this is addressed soon so that proper treatment can be given.
An increase in blood pressure-rationale: assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, an elevated cvp, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit. options a, b, and d identify signs noted in deficient fluid volume.test-taking strategy: use the process of elimination and knowledge regarding the assessment findings in excess fluid volume. note that options a, b, and d are similar or alike in that each of these signs reflects a decrease. option c reflects an increase. if you had difficulty with this question, review the assessment findings noted in excess fluid volume.