A patient who has heart failure and difficulty breathing is being admitted. Which physical assessment(s) indicate(s) fluid volume excess? (Select all that apply.)
a. Rapid, bounding, irregular pulse rate
b. Clear lung sounds
c. 3+ pitting ankle edema
d. Neck vein engorgement
e. Shortness of breath
ANS: A, C, D, E
The patient with overhydration caused by heart failure often presents with a rapid and irregular pulse rate, peripheral and abdominal edema, distended neck veins, dyspnea and adventitious breath sounds of crackles and/or rhonchi in lung fields.
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