When being discharged home, to assess fluid balance, a client with heart failure should be instructed to:
Monitor blood pressure.
Assess radial pulses.
Monitor bowel movements.
Monitor weight daily.
The Correct Answer is D
A. Monitor blood pressure – While important, blood pressure changes are not the most sensitive or early indicator of fluid retention in heart failure.
B. Assess radial pulses – Pulse assessment can reflect cardiac output, but it does not directly indicate fluid balance.
C. Monitor bowel movements – Bowel function is not typically affected by fluid balance in heart failure and is not a relevant measure.
D. Monitor weight daily – Daily weight monitoring is the most accurate and early indicator of fluid retention in clients with heart failure. A weight gain of 2–3 pounds in a day or 5 pounds in a week may indicate fluid overload and should be reported to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ventricular tachycardia presents with wide QRS complexes (usually >0.12 second), and the rhythm is typically regular—not irregular as seen here.
B. Sinus tachycardia has identifiable P waves before each QRS complex and a regular rhythm, which is not the case here.
C. Ventricular fibrillation presents as a chaotic, irregular waveform with no identifiable QRS complexes, resulting in no effective cardiac output—this is more severe than the rhythm described.
D. Atrial fibrillation is characterized by the absence of P waves, irregularly irregular rhythm, wavy baseline (fibrillatory waves), and often a rapid ventricular response, such as the heart rate of 120 bpm observed in this client.
Correct Answer is D
Explanation
A. Platelets are administered to treat or prevent bleeding due to thrombocytopenia or platelet dysfunction, not primarily for volume loss.
B. Albumin is a plasma volume expander and may be used in hypovolemia, but it does not replace oxygen-carrying capacity like RBCs do.
C. Cryoprecipitates are rich in clotting factors (e.g., fibrinogen, factor VIII) and are used for coagulopathies, not as a primary treatment for hypovolemic shock.
D. Packed RBCs are the appropriate choice in hypovolemic shock, especially when blood loss has occurred, as they restore oxygen-carrying capacity and circulating blood volume.
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