Identify the actions the nurse should take to manage this patient’s heart failure effectively. (Select all that apply)

Choice A reason: Encouraging fluid intake worsens heart failure by increasing preload and congestion. Restriction (e.g., 2L/day) is standard to prevent overload, as excess volume exacerbates dyspnea and edema in compromised hearts.

Choice B reason: Administering diuretics like furosemide reduces fluid overload, easing heart failure symptoms. It lowers pulmonary pressure and edema by enhancing excretion, a critical action to stabilize patients and improve breathing.

Choice C reason: Monitoring weight and fluid balance tracks retention in heart failure; a 2-3 lb gain signals worsening. It guides therapy adjustments, ensuring effective management of volume status and preventing decompensation.

Choice D reason: Educating on low-sodium diets (<2g/day) prevents fluid retention in heart failure. Sodium draws water into vessels, worsening congestion; this empowers patients to control symptoms and supports long-term stability.

Choice A reason: Pleural effusion with chest discomfort suggests fluid buildup, causing pain but not immediate airway compromise. It’s stable compared to tracheal deviation, prioritizing respiratory distress over this less acute issue.

Choice B reason: Cor pulmonale with 4+ edema indicates chronic right heart failure, a serious but slower process. It’s less urgent than acute airway obstruction, as it’s manageable with diuretics, not an immediate threat.

Choice C reason: Tracheal deviation post-catheter insertion signals tension pneumothorax, a life-threatening emergency. It compresses airways and vessels, requiring immediate assessment and intervention to restore breathing and circulation.

Choice D reason: Fever of 101°F post-lung transplant suggests infection or rejection, critical but not airway-immediate. It’s urgent, yet tracheal deviation’s acute respiratory collapse takes precedence over this systemic concern.