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.
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Related Questions
Correct Answer is D
Explanation
A. "I will have canned chicken noodle soup with crackers and an apple for lunch": Canned soups are often high in sodium, and crackers can also contribute to sodium intake. This meal choice would not align with a low-sodium diet.
B. "I will have a ham and cheese sandwich for lunch": Processed meats like ham and cheese can be high in sodium, especially if they are not low-sodium options. This choice may not be suitable for a low-sodium diet unless specific low-sodium products are used.
C. "I will have a BLT and a side salad with cheese and croutons for lunch": Bacon, cheese, and croutons are all sources of sodium, so this meal would likely not be appropriate for a low-sodium diet unless modifications are made, such as using low-sodium bacon and limiting cheese and crouton amounts.
D. "I will have a baked potato with broiled chicken for dinner": This statement indicates an understanding of choosing low-sodium options. Baked potatoes and broiled chicken are generally low in sodium, especially if prepared without added salt or high-sodium seasonings. This choice aligns well with a low-sodium diet for someone with heart failure.
Correct Answer is A
Explanation
A. "If I take my blood pressure and it is normal, I don't have to take my blood pressure pills": This statement reflects a misunderstanding of hypertension management. Blood pressure medications are typically prescribed to help control blood pressure over the long term, regardless of individual blood pressure readings. Stopping medication without consulting a healthcare provider can be dangerous and is not recommended.
B. "When getting up from bed, I will sit for a short period before standing up": This statement demonstrates an understanding of orthostatic hypotension prevention, which is important for clients with hypertension and can be a side effect of certain medications.
C. "I will consult a dietician to help get my weight under control": This statement indicates the client's awareness of the importance of weight management in hypertension control and is a positive step toward healthy lifestyle changes.
D. "I think I'm going to sign up for a yoga class twice a week to help reduce my stress": This statement shows the client's proactive approach to stress reduction, which is beneficial for hypertension management as stress can contribute to elevated blood pressure.
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