The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting?
Monitor weight daily
Assess radial pulses daily
Monitor bowel movements
Monitor blood pressure daily
The Correct Answer is A
A. Monitor weight daily: Daily weight monitoring is a crucial aspect of assessing fluid balance in clients with heart failure. Sudden weight gain can indicate fluid retention, which may be a sign of worsening heart failure. The nurse should instruct the client to weigh themselves at the same time each day, preferably in the morning after emptying the bladder and before eating breakfast, and to report any significant weight changes to their healthcare provider.
B. Assess radial pulses daily: While assessing radial pulses is important for monitoring cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Radial pulse assessment is more related to evaluating cardiac output and peripheral perfusion.
C. Monitor bowel movements: Monitoring bowel movements is not directly related to assessing fluid balance in heart failure. Although changes in bowel habits can sometimes be associated with fluid and electrolyte imbalances, it is not the primary method for assessing fluid balance in this context.
D. Monitor blood pressure daily: While monitoring blood pressure is important for managing hypertension and evaluating cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Blood pressure monitoring is more related to assessing hemodynamic stability and response to medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["5"]
Explanation
To calculate how many milliliters (mL) of metoprolol 1 mg/mL solution should be administered to deliver a 5 mg IV bolus dose, you can use the following formula:
Dose (mL) = Desired dose (mg) / Concentration (mg/mL)
In this case:
Desired dose = 5 mg
Concentration = 1 mg/mL
Dose (mL) = 5 mg / 1 mg/mL = 5 mL
Therefore, the nurse should administer 5 mL of metoprolol 1 mg/mL solution per dose to deliver a 5 mg IV bolus for heart rate control.
Correct Answer is ["1712.32"]
Explanation
To calculate the client's total intake for the 8-hour shift, we need to convert all the volumes to milliliters (mL) and then add them together. Here are the given volumes and their conversions:
1,000 mL 0.9% sodium chloride IV (no conversion needed)
One 6-oz cup of coffee:
6 oz * 29.5735 (conversion factor for oz to mL) = approximately 177.44 mL
6 oz of water:
6 oz * 29.5735 = approximately 177.44 mL
One 180-mL bowl of soup (no conversion needed)
3 oz of flavored gelatin:
3 oz * 29.5735 = approximately 88.72 mL
3 oz of ice cream:
3 oz * 29.5735 = approximately 88.72 mL
Now, let's add up all the volumes:
1,000 mL (IV fluid) + 177.44 mL (coffee) + 177.44 mL (water) + 180 mL (soup) + 88.72 mL (gelatin) + 88.72 mL (ice cream) = 1,712.32 mL
Therefore, the nurse should document the client's total intake for the shift as approximately 1,712.32 mL.
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