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 ["125"]
Explanation
To calculate the infusion rate in mL/hr, you can use the formula:
Infusion rate (mL/hr) = Total volume (mL) / Total time (hr)
In this case, the total volume is 1000 mL and the total time is 8 hours.
Infusion rate = 1000 mL / 8 hr
Infusion rate ≈ 125 mL/hr
The nurse should set the IV pump to deliver approximately 125 mL/hr.
Correct Answer is B
Explanation
A. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion.": Cardiac enzymes are not used to diagnose pulmonary congestion. They are specific markers used to assess damage to the heart muscle, particularly after a myocardial infarction (MI).
B. "These tests help determine the degree of damage to the heart tissues.": This statement is correct. Cardiac enzyme studies, such as troponin levels, CK-MB (creatine kinase-MB), and LDH (lactate dehydrogenase), are used to evaluate the extent of myocardial damage during and after an MI. Elevated levels of these enzymes indicate myocardial injury.
C. "These tests will enable the provider to determine the heart structure.": While cardiac imaging studies like echocardiograms or angiograms are used to assess heart structure, cardiac enzymes are primarily used to evaluate myocardial damage and not heart structure.
D. "Cardiac enzymes will identify the location of the MI.": Cardiac enzymes can indicate the presence of an MI and the extent of myocardial damage, but they do not specifically identify the location of the MI within the heart. Additional diagnostic tests, such as electrocardiograms (ECGs) and imaging studies, are often used to determine the location of the MI.
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