A patient with congestive heart failure is at risk of excess fluid volume. Which intervention will best determine if the patient is beginning to have excess fluid volume?
Daily intake and output recordings
Daily weights
Daily blood pressure and heart rate checks
Daily CMP lab draw
The Correct Answer is B
Daily weights provide a reliable and accurate measure of fluid balance in the body. An increase in weight can indicate fluid retention and the need for further intervention. While daily intake and output recordings, blood pressure and heart rate checks, and CMP lab draws can also provide useful information, daily weights are the most effective way to monitor for excess fluid volume in this situation.
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Related Questions
Correct Answer is B
Explanation
Fluid retention is a common complication in heart failure, and monitoring the client's fluid status is crucial to manage the condition effectively. Daily weights are an essential component of monitoring fluid status and are the most sensitive and practical method to detect changes in the client's fluid status. Weight gain is a reliable indicator of fluid retention, and even small increases in weight can indicate the need for changes in the client's treatment plan.
Although electrolyte monitoring (option a), output measurements (option c), and daily BUN and serum creatinine monitoring (option d) can provide valuable information about the client's fluid status, they are not as sensitive or practical as daily weights. Electrolyte monitoring can help detect changes in fluid balance, but it does not provide a direct indication of fluid status. Output measurements can indicate fluid loss, but they do not provide an accurate assessment of fluid retention. BUN and serum creatinine monitoring can detect changes in renal function, but they are not specific to fluid status.
Correct Answer is A
Explanation
The client's greenish-yellow sputum with a musty odor may indicate an infection, such as pneumonia or bronchitis, which can affect the client's lung function. By auscultating bilateral breath sounds, the nurse can assess for the presence of abnormal lung sounds, such as crackles or wheezing, which may indicate further respiratory compromise.
While obtaining a blood culture for tuberculosis (option b) may be appropriate in certain circumstances, the client's sputum color and odor do not necessarily indicate tuberculosis as the cause of their respiratory symptoms.
Requesting pulmonary function studies (option c) may also be beneficial in assessing the client's lung function, but this is not the priority assessment in this situation.
Finally, while documenting the findings (option d) is an important aspect of nursing care, it is not the priority action when the client is presenting with signs of compromised lung function.
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