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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Positioning the collection device below the level of the chest is crucial to ensure proper drainage of air or fluid from the pleural space. This positioning uses gravity to facilitate drainage and prevent backflow into the pleural cavity, which could lead to complications such as pneumothorax or pleural effusion. The collection device should always be kept below the chest level to maintain effective drainage.
Choice B reason: Clamping the chest tube is generally not recommended unless specifically ordered by a physician or during certain procedures. Clamping can lead to a buildup of air or fluid in the pleural space, increasing the risk of tension pneumothorax. It is essential to keep the chest tube unclamped to allow continuous drainage and prevent complications.
Choice C reason: Applying an occlusive dressing over the chest tube site is necessary to prevent air from entering the pleural space and to secure the tube. However, this is not the primary action related to the positioning of the collection device. The occlusive dressing helps maintain the integrity of the chest tube insertion site and prevents infection.
Choice D reason: Emptying the chest tube collection chamber every shift is not a standard practice. The collection chamber should be monitored and emptied as needed based on the volume of drainage and the specific protocols of the healthcare facility. Regular monitoring is essential, but unnecessary emptying can disrupt the closed system and increase the risk of infection.
Correct Answer is B
Explanation
Choice A reason: Reminding the client that a signed informed consent form is a legally binding document is incorrect. Informed consent is based on the principle of patient autonomy, meaning the patient has the right to withdraw consent at any time. The nurse should respect the client’s decision and not pressure them into proceeding with the procedure.
Choice B reason: Notifying the surgeon that the client wishes to withdraw informed consent for the procedure is the appropriate action. The surgeon needs to be informed immediately so that they can discuss the client’s concerns, provide additional information if needed, and respect the client’s decision. This ensures that the client’s autonomy and rights are upheld.
Choice C reason: Proceeding with preparation of the patient for the surgical procedure is not appropriate once the client has withdrawn consent. Continuing with the preparation would violate the client’s rights and could lead to legal and ethical issues. The nurse must halt any further preparation and inform the relevant medical staff of the client’s decision.
Choice D reason: Informing the surgical team to cancel the client’s surgery is a step that may be taken after discussing the withdrawal of consent with the surgeon. The nurse should first notify the surgeon, who will then make the decision to cancel the surgery based on the client’s wishes. Directly informing the surgical team without consulting the surgeon first is not the correct protocol.
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