When assessing a patient for signs of fluid overload, the nurse would expect to observe:
A. Bounding pulse
B. Flat neck veins
C. Poor skin turgor
D. Vesicular
Correct Answer: A. Bounding pulse
Bounding pulse is a sign of fluid overload as more volume in the vessels causes a stronger sensation against the blood vessel walls. Assess for bounding peripheral pulses and S3. These assessment findings are signs of fluid overload.
Option B: Flat neck veins and vesicular breath sounds are normal findings. Check for distended neck veins and ascites. Monitor abdominal girth to follow any ascites accurately. Distended neck veins are caused by elevated CVP. Ascites occur when fluid accumulates in extravascular spaces.
Option C: Poor skin turgor is consistent with dehydration. Note for the presence of edema by palpating over the tibia, ankles, feet, and sacrum. Edema occurs when fluid accumulates in the extravascular spaces. Dependent areas more readily exhibit signs of edema formation.
Option D: Assess for crackles in the lungs, changes in respiratory pattern, shortness of breath, and orthopnea. These signs are caused by an accumulation of fluid in the lungs.
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