HESI Registered Nurse EXIT Practice Exam

If a client develops volume overload from rapid IV infusion, what assessment finding would the nurse expect?

1. S3 heart sound

2. Thready pulse

3. Flattened neck veins

4. Hypoventilation

The correct answer is: S3 heart sound

When a client experiences volume overload due to rapid intravenous infusion, one of the key signs that can be observed during assessment is the presence of an S3 heart sound. An S3 heart sound, sometimes referred to as a "ventricular gallop," can indicate increased fluid volume in the heart, which often results from conditions such as heart failure or volume overload. This sound occurs during the rapid filling phase of the ventricles when there is an excess of fluid that causes the heart to work harder, leading to an altered hemodynamic state. In cases of volume overload, the heart is challenged by an increase in blood volume returning to it, which can cause a stretch of the ventricles and result in this additional heart sound. The presence of an S3 may point towards the potential for heart failure, making it a significant finding in this clinical context. Although other options may reflect different physiological states, they do not directly correlate with the heart's response to volume overload as clearly as the S3 heart sound. For instance, a thready pulse might suggest inadequate stroke volume or perfusion, flattened neck veins can indicate hypovolemia rather than overload, and hypoventilation is more associated with respiratory issues than fluid volume changes. Therefore, the