A home health nurse is collecting data from a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?
Document the findings and continue with the visit.
Notify the RN case manager of the change in status.
Reinforce the importance of daily weights.
Ensure the client has been taking their prescribed diuretic.
The Correct Answer is B
A. Documenting the findings and continuing the visit does not address the potential seriousness of the weight gain and edema in a patient with heart failure. It is important to act promptly on such findings.
B. Notifying the RN case manager of the change in status is essential because a weight gain of this magnitude, along with generalized edema, may indicate worsening heart failure. This requires a timely assessment and possible adjustment of the treatment plan, including medication and fluid management.
C. While reinforcing the importance of daily weights is beneficial for long-term management, it is not an immediate intervention for the acute change in the patient’s condition.
D. Ensuring the client has been taking their prescribed diuretic is important, but the nurse should first communicate the significant changes to the RN case manager for further evaluation and intervention, as this might require a medication review or adjustment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Decreasing activity is not recommended for peripheral venous disease; clients are encouraged to engage in physical activity to promote circulation and prevent complications.
B. Massaging legs may not be advisable as it could exacerbate swelling and discomfort; instead, elevation is often recommended.
C. Inspecting legs daily for changes is essential for early detection of complications such as skin changes or ulcers, indicating the client understands the importance of monitoring their condition.
D. Keeping legs in a dependent position can worsen venous pooling and swelling; elevation is generally recommended to improve venous return.
Correct Answer is B
Explanation
A. Shopping for shoes in the morning is not recommended, as feet tend to swell later in the day, and shoe fitting should account for potential swelling.
B. Incorporating walking into the daily routine helps improve circulation and can aid in managing peripheral vascular disease by promoting blood flow in the legs.
C. Elevating the legs might decrease circulation and is not advised for clients with peripheral vascular disease, as it can reduce blood flow to the extremities.
D. Knee-length stockings can restrict circulation, especially if they are too tight, and should be avoided to promote proper blood flow in clients with this condition.
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