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 C
Explanation
A. Strict bed rest is not the priority; early mobility may be encouraged once the patient is stable.
B. Pain management is important but not the first priority in septic shock.
C. Monitoring vital signs frequently is the priority because it allows the nurse to detect changes in perfusion, blood pressure, heart rate, and oxygenation status, which are critical for timely intervention in septic shock.
D. Assisting with hygiene is part of routine care but is not a priority during the acute management of septic shock.
Correct Answer is B
Explanation
A. Transcutaneous pacing may be considered if the bradycardia does not respond to initial medical management, but it is not the first intervention.
B. Administering atropine IV is the first-line treatment for symptomatic bradycardia. Atropine works by increasing heart rate through its anticholinergic effects, helping to improve cardiac output and consciousness.
C. CPR is only indicated if the client is pulseless or not breathing. Since this client is still breathing, CPR is not appropriate at this stage.
D. Cardioversion is used for certain tachyarrhythmias (e.g., atrial fibrillation with rapid ventricular response), not for bradycardia.
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