HESI Registered Nurse EXIT Practice Exam

Which assessment finding in a client with heart failure would indicate fluid overload?

1. Increased urinary output

2. Weight loss

3. Elevated blood pressure

4. Shortness of breath

The correct answer is: Shortness of breath

In the context of heart failure, shortness of breath, or dyspnea, is a common indicator of fluid overload. This occurs due to the heart's decreased ability to pump blood effectively, leading to a backlog of fluid in the lungs. When fluid accumulates in the pulmonary circulation, it can cause pulmonary congestion, which manifests as difficulty breathing, particularly when the client exerts themselves or lies flat. Shortness of breath in a client with heart failure often correlates with other signs of fluid overload, such as crackles upon auscultation of the lungs or orthopnea (difficulty breathing while lying down). Recognizing this symptom can help healthcare providers manage heart failure more effectively by initiating interventions to reduce fluid accumulation, such as diuretics or adjusting fluid intake. In contrast, increased urinary output typically suggests effective kidney function and may indicate fluid mobilization, while weight loss is generally associated with improved health rather than fluid overload. Elevated blood pressure can occur in various conditions and does not specifically indicate fluid overload in heart failure, as blood pressure can be influenced by numerous other factors. Thus, shortness of breath is a direct and significant assessment finding indicative of fluid overload in clients with heart failure.