Medical Surgical Renal Failure #4

Question

The nurse is caring for a client in acute renal failure. Which assessment findings by the nurse indicates hypervolemia in this client? Select all that apply.

Answers

  1. S3 gallop
    • Rationale:

      This answer is correct because an S3 gallop indicates pulmonary edema. S3 gallop is an “extra” cardiac heart sound heard after the first two heart sounds. This extra heart sound is a result of ventricular overload from a high preload due to fluid volume excess in renal failure.

  2. Lung crackles
    • Rationale:

      This answer is correct because lung crackles are heard when there is fluid in the alveoli. Renal failure causes fluid in the blood vessels. In the lungs during renal failure, instead of the alveoli taking in oxygen, they take in fluid that has leaked from these blood vessels. This results in a crackling sound heard on auscultation of the lungs.

  3. Bradycardia
    • Rationale:

      This answer is not correct because tachycardia, not bradycardia, is an assessment finding of hypervolemia. The heart speeds up to adequately pump the large amount of blood volume caused by the renal failure throughout the body.

  4. ½ lb weight gain
    • Rationale:

      This answer is not correct because a weight gain of ½ lb is irrelevant. A weight gain of 2 to 3 pounds in 24 hours is significant in the client in renal failure and indicates hypervolemia.

  5. Hypotension
    • Rationale:

      This answer is not correct because hypertension (not hypotension) is associated with hypervolemia. This is because the extra fluid pushes on the walls of the blood vessels.

Overview

A client in acute renal failure is at risk for hypervolemia. Assessment findings include S3 gallop, lung crackles, tachycardia, a 2-3 pound weight gain, and hypertension.

Explanation

Learning Outcomes

A client in acute renal failure is at risk for hypervolemia. Assessment findings include S3 gallop, lung crackles, tachycardia, a 2-3 pound weight gain and hypertension. S3 gallop is an “extra” cardiac heart sound heard after the first two heart sounds. This extra heart sound is a result of ventricular overload from a high preload due to fluid volume excess in renal failure. This causes pulmonary edema. Lung crackles will be heard when there is pulmonary edema. The alveoli fill with fluid instead of oxygen due to leakage of blood vessels from the excess fluid. In order to adequately pump the larger amount of blood volume, the heart beats faster to compensate. Due to the excess fluid volume, a weight gain of over 2 pounds may occur.

Test Taking Tip

Know the assessment findings of hypervolemia and hypovolemia.

Video Rationale