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What is the best indication if the client with congestive heart failure is holding excess fluid?

A.

Intake and output

B.

Pitting pedal edema

C.

Crackles in the bases of the lungs

D.

Daily weights

Answer and Explanation

The Correct Answer is D

A. Intake and output:

Intake and output refer to monitoring the amount of fluids a person consumes (intake) and eliminates (output) through urine, feces, and other means. While tracking fluid intake and output is important, it may not provide a direct indication of excess fluid retention.

B. Pitting pedal edema:

Pitting pedal edema is swelling in the lower extremities, particularly the ankles and feet, that leaves an indentation (pit) when pressure is applied. This can be a sign of fluid retention but may not always be the earliest or most reliable indicator.

C. Crackles in the bases of the lungs:

Crackles or rales in the bases of the lungs can be indicative of pulmonary congestion, which may occur due to fluid accumulation. However, crackles alone may not always be specific to fluid overload and can be present in other respiratory conditions.

D. Daily weights:

Daily weights are a critical and sensitive measure for assessing fluid balance. Sudden weight gain, especially over a short period, can be a strong indicator of fluid retention. Monitoring weight on a daily basis helps to detect changes early, allowing for prompt intervention.


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Related Questions

Correct Answer is ["50"]

Explanation

To calculate the drops per minute for the ondansetron infusion, we need to use the formula:

drops per minute = (volume in mL x drop factor) / time in minutes

In this case, the volume is 50 mL, the drop factor is 15 gtt/mL, and the time is 15 minutes. Plugging these values into the formula, we get:

drops per minute = (50 x 15) / 15

drops per minute = 750 / 15

drops per minute = 50

Therefore, the nurse should set the infusion pump to deliver 50 drops per minute of ondansetron to the client with severe nausea.

Correct Answer is D

Explanation

A. The client with a history of a myocardial infarction who has a p wave before every QRS complex.

This may indicate a heart block, which requires attention. However, it's not an immediate life-threatening situation.

B. The client diagnosed with heart failure who has bilateral 2+ pitting pedal edema.

Bilateral pitting pedal edema is a sign of fluid overload, which is concerning and requires attention.

C. The client with sinus bradycardia (HR 56/min) that is reporting fatigue.

While bradycardia and fatigue are concerns, they might not be as urgent as the client with fluid overload.

D. The client diagnosed with coronary artery disease who is now reporting new onset of severe indigestion.

New onset of severe indigestion in a client with coronary artery disease raises concern for a potential cardiac event, and this should be addressed promptly.

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