HESI Registered Nurse EXIT Practice Exam

What assessment finding indicates fluid overload in a heart failure patient?

1. Orthopnea

2. Low blood pressure

3. Thready pulse

4. Bradycardia

The correct answer is: Orthopnea

Orthopnea is a classic assessment finding that indicates fluid overload, particularly in patients with heart failure. It refers to the difficulty or discomfort in breathing that occurs when lying flat and is relieved by sitting up. This symptom arises because lying down increases venous return to the heart and subsequently the volume of blood the heart has to pump. In the context of heart failure, the heart may not be able to effectively manage this increased volume, leading to pulmonary congestion and further exacerbation of breathing difficulties. In heart failure patients, orthopnea is commonly linked to fluid retention which can manifest as symptoms of congestion, including dyspnea (shortness of breath) when supine. By recognizing orthopnea, healthcare providers can assess the severity of fluid overload and adjust treatment strategies accordingly. It is crucial to monitor such symptoms closely to manage and improve the patient's respiratory status and overall well-being.