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 A
Explanation
A. Ventricular tachycardia is characterized by a ventricular rate >100 bpm, regular rhythm, no visible P waves, and wide QRS complexes (>0.12 seconds). The findings described—ventricular rate of 162, regular R-R intervals, no visible P waves, and a QRS duration of 0.18 seconds—are consistent with ventricular tachycardia.
B. Ventricular fibrillation shows a chaotic, irregular rhythm with no identifiable QRS complexes, which is not the case here.
C. Sinus tachycardia would have visible P waves and a normal QRS duration.
D. Atrial flutter typically has "sawtooth" flutter waves and a more organized atrial rhythm with a distinct P wave pattern, which is absent in this scenario.
Correct Answer is B
Explanation
A. Airway: Ensure the airway is open.
B. Breathing: Provide rescue breaths if the person is not breathing.
C. Circulation: Begin chest compressions to maintain blood flow.
D. Defibrillation: Use an automated external defibrillator (AED) as soon as it's available, especially in cases of shockable rhythms like ventricular fibrillation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.