A client is hospitalized with worsening chronic heart failure. Which clinical manifestations does the admitting nurse most likely assess in this client? Select all that apply.

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11ecbb05_c922_6e11_b433_4307a8d8ecfd_MD0009_00 Clients with a diagnosis of chronic congestive heart failure experience clinical manifestations of both right-sided (systemic venous congestion) and left-sided (pulmonary congestion) failure. Crackles are discontinuous, adventitious lung sounds usually heard on inspiration and indicate the presence of pulmonary congestion (left-sided failure) in this client. Increased jugular venous distention reflects an increase in pressure and volume in the systemic circulation, resulting in elevated central venous pressure (CVP) (right-sided failure) in this client. Although dependent pitting edema of the extremities can be associated with other conditions (eg, hypoproteinemia, venous insufficiency), it is related to sodium and fluid retention (right-sided failure) in this client. (Option B) Dry mucous membranes are associated with dehydration (increased serum sodium level), not fluid overload (heart failure). (Option D) Rhonchi are continuous lung sounds usually heard on expiration that indicate the presence of secretions in the larger airways. They are not a classic manifestation of chronic heart failure. (Option E) Poor skin turgor or "tenting" is associated with skin moisture and elasticity. It is usually associated with dehydration, not fluid overload. Educational objective: Clients with chronic heart failure experience clinical manifestations of both right-sided and left-sided failure. Therefore, the nurse must be able to assess for the clinical manifestations related to systemic volume increases and pulmonary congestion.

A Client Is Hospitalized with Worsening Chronic Heart Failure