A nurse is assessing a client with congestive heart failure (CHF). Which assessment tool will provide a reliable measure of fluid retention for this client?

Cardiac monitoring

Daily weight measurement

Blood pressure monitoring

Urine output measurement

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Cardiac monitoring involves the continuous observation of the heart’s electrical activity, typically using an electrocardiogram (ECG). While cardiac monitoring is essential for detecting arrhythmias and other cardiac events, it does not directly measure fluid retention. Fluid retention in CHF patients can lead to symptoms such as edema and weight gain, which are not directly assessed through cardiac monitoring.

Choice B Reason:

Daily weight measurement is a reliable and practical method for assessing fluid retention in clients with congestive heart failure. Fluid retention leads to an increase in body weight, and monitoring daily weight changes can help detect fluid accumulation early. A sudden weight gain of more than 2-3 pounds in a day or 5 pounds in a week is a significant indicator of fluid retention and worsening heart failure. This method is non-invasive, easy to perform, and provides valuable information for managing CHF.

Choice C Reason:

Blood pressure monitoring is crucial for managing clients with CHF, as hypertension can exacerbate heart failure. However, blood pressure readings alone do not provide a direct measure of fluid retention. While fluid overload can affect blood pressure, it is not a specific or sensitive indicator of fluid status. Blood pressure monitoring should be used in conjunction with other assessment tools to manage CHF effectively.

Choice D Reason:

Urine output measurement is an important parameter for assessing kidney function and fluid balance. In clients with CHF, reduced urine output can indicate worsening heart failure and fluid retention. However, urine output alone may not provide a complete picture of fluid status, especially if the client is on diuretic therapy. Daily weight measurement remains a more direct and reliable method for assessing fluid retention in CHF patients.

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Correct Answer is C

Explanation

Choice A Reason:

Lubricate the suction catheter tip with sterile saline is important to ensure smooth insertion and reduce trauma to the tracheal mucosa. However, this is not the first step. Preoxygenation is crucial to prevent hypoxia during the suctioning process.

Choice B Reason:

Perform chest physiotherapy prior to suctioning can help mobilize secretions, making them easier to remove. While beneficial, it is not the immediate first step. Ensuring the client is adequately oxygenated takes precedence.

Choice C Reason:

Hyperventilate the client on 100% oxygen prior to suctioning is correct. This step is essential to prevent hypoxia during suctioning. Suctioning can temporarily reduce oxygen levels, so preoxygenating the client helps maintain adequate oxygenation throughout the procedure.

Choice D Reason:

Suction two to three times with a 60-second pause between passes is a recommended practice to allow the client to recover between suctioning attempts. However, this step follows the initial preoxygenation.

A. Place suction equipment at the bedside. B. Administer a prophylactic expectorant. C. Encourage the use of an incentive spirometer. D. Perform range of motion exercises.

Correct Answer is C

Explanation

Choice A Reason:

Place suction equipment at the bedside is incorrect. While having suction equipment available is important for emergency situations, it does not directly prevent postoperative pulmonary complications. Suction equipment is used to clear the airway if the client has difficulty breathing or if there is an obstruction.

Choice B Reason:

Administer a prophylactic expectorant is incorrect. Prophylactic expectorants can help in managing secretions, but they are not the primary intervention for preventing postoperative pulmonary complications. The main goal is to promote lung expansion and prevent atelectasis.

Choice C Reason:

Encourage the use of an incentive spirometer is correct. Using an incentive spirometer encourages deep breathing and lung expansion, which helps prevent atelectasis and other postoperative pulmonary complications. It is a key intervention in postoperative care to maintain optimal lung function.

Choice D Reason:

Perform range of motion exercises is incorrect. While range of motion exercises are important for preventing musculoskeletal complications and promoting circulation, they do not directly prevent pulmonary complications. The focus for pulmonary health is on lung expansion and clearing secretions.

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