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NCLEX · Cardiac Care

A nurse is caring for a client with heart failure. Which symptoms would indicate worsening fluid overload?

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Correct answer

Sudden weight gain, increased shortness of breath, edema, and crackles in the lungs

  1. A Decreased heart rate only
  2. B Improved exercise tolerance
  3. C Weight loss and increased urination
  4. D Sudden weight gain, increased shortness of breath, edema, and crackles in the lungs

Why this is the answer

Worsening HEART FAILURE / FLUID OVERLOAD signs include: SUDDEN WEIGHT GAIN (the most sensitive early indicator — fluid retention; a gain of 2-3 lbs in a day or 5 lbs in a week should be reported); increased SHORTNESS OF BREATH (dyspnea, orthopnea, paroxysmal nocturnal dyspnea); EDEMA (swelling, especially legs/ankles); CRACKLES (rales) in the lungs (pulmonary congestion); jugular vein distension; fatigue; cough. NCLEX physiological/cardiac.

Teaching: weigh daily (same time, same scale, same clothing) and report rapid gains; low-sodium diet; take medications (diuretics, etc.); monitor symptoms. Daily weight is the key self-monitoring tool. Recognizing worsening heart failure (especially sudden weight gain) is a commonly tested NCLEX concept.

Source: NCLEX Physiological — Heart Failure Fluid Overload

Practice more questions

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About this topic: Cardiac Care

Cardiac care questions cover chest pain assessment, MI and heart failure management, dysrhythmia recognition, cardiac medications and the post-procedure care after catheterisation. This is one of 10 RN: Physiological Integrity questions on cardiac care, each with a full explanation on a single study page.

New to this exam? Our NCLEX exam guide explains the format, scoring, and how to prepare.

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