What is the best indication if the client with congestive heart failure is holding excess fluid?
Intake and output
Pitting pedal edema
Crackles in the bases of the lungs
Daily weights
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Shortness of breath
Shortness of breath can be a symptom of a myocardial infarction in both men and women.
B. Anxiety
Anxiety can be a symptom in some cases, as individuals may feel a sense of impending doom or anxiety during an MI.
C. Unusual fatigue
Unusual fatigue, especially if it is severe or occurs with exertion, can be a symptom of a myocardial infarction.
D. Back pain
Back pain, particularly between the shoulder blades, can be a symptom of a myocardial infarction in women.
E. Chest pain
Chest pain or discomfort is a classic symptom of a myocardial infarction. While women may experience chest pain, they are also more likely than men to have atypical symptoms.
Correct Answer is ["A","B","C","D"]
Explanation
Withhold food and oral fluids before the procedure
Withholding food and oral fluids before the procedure is essential to prevent complications during the cardiac catheterization. The client is typically NPO (nothing by mouth) for a specified period before the procedure.
B. Review medications the client has taken in the last 24 hours
Reviewing the client's medications is crucial to ensure that any medications affecting coagulation or blood vessels are appropriately managed before the cardiac catheterization.
C. Verify that written consent has been obtained
Verifying the presence of written consent is a critical step to confirm that the client has been adequately informed about the procedure, its risks, and benefits, and has given consent for the cardiac catheterization.
D. Check for iodine sensitivity
Checking for iodine sensitivity is important because iodinated contrast dye is commonly used during cardiac catheterization. Allergies or sensitivities to iodine contrast must be identified to prevent adverse reactions.
E. Administer all ordered oral medications
Administration of oral medications before the procedure depends on the specific medications and the healthcare provider's instructions. Some medications may be held, while others may be continued as prescribed.

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