A nurse is assessing a client with congestive heart failure (CHF). Which assessment tool will provide a reliable measure of fluid retention for this client?
Cardiac monitoring
Daily weight measurement
Blood pressure monitoring
Urine output measurement
The Correct Answer is B
Choice A Reason:
Cardiac monitoring involves the continuous observation of the heart’s electrical activity, typically using an electrocardiogram (ECG). While cardiac monitoring is essential for detecting arrhythmias and other cardiac events, it does not directly measure fluid retention. Fluid retention in CHF patients can lead to symptoms such as edema and weight gain, which are not directly assessed through cardiac monitoring.
Choice B Reason:
Daily weight measurement is a reliable and practical method for assessing fluid retention in clients with congestive heart failure. Fluid retention leads to an increase in body weight, and monitoring daily weight changes can help detect fluid accumulation early. A sudden weight gain of more than 2-3 pounds in a day or 5 pounds in a week is a significant indicator of fluid retention and worsening heart failure. This method is non-invasive, easy to perform, and provides valuable information for managing CHF.
Choice C Reason:
Blood pressure monitoring is crucial for managing clients with CHF, as hypertension can exacerbate heart failure. However, blood pressure readings alone do not provide a direct measure of fluid retention. While fluid overload can affect blood pressure, it is not a specific or sensitive indicator of fluid status. Blood pressure monitoring should be used in conjunction with other assessment tools to manage CHF effectively.
Choice D Reason:
Urine output measurement is an important parameter for assessing kidney function and fluid balance. In clients with CHF, reduced urine output can indicate worsening heart failure and fluid retention. However, urine output alone may not provide a complete picture of fluid status, especially if the client is on diuretic therapy. Daily weight measurement remains a more direct and reliable method for assessing fluid retention in CHF patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Applying compression stockings is a key prophylactic intervention to prevent complications of immobility, such as deep vein thrombosis (DVT) and venous thromboembolism (VTE). Compression stockings help improve blood circulation in the legs by applying graduated pressure, which reduces the risk of blood clots forming in the deep veins. This is particularly important for immobile patients who are at higher risk of developing DVT due to prolonged periods of inactivity.
Choice B reason: Raising all side rails is primarily a safety measure to prevent falls and does not directly address the complications of immobility. While it is important for patient safety, it does not have a significant impact on preventing issues like DVT, pressure ulcers, or muscle atrophy. Therefore, it is not considered a prophylactic intervention for immobility-related complications.
Choice C reason: Inserting a urinary catheter is not a prophylactic intervention for preventing complications of immobility. Catheters are used to manage urinary retention or incontinence but can increase the risk of urinary tract infections (UTIs) if not managed properly. They do not address the primary complications associated with immobility, such as DVT or pressure ulcers.
Choice D reason: Using friction-reducing devices is important for preventing pressure ulcers and skin injuries in immobile patients. These devices help minimize friction and shear forces on the skin, which can lead to pressure ulcers. While this is a valuable intervention, it is not as comprehensive as compression stockings in preventing a range of immobility-related complications.
Correct Answer is A
Explanation
Choice A Reason:
Loperamide should not be used if diarrhea is infectious is correct. Loperamide is an antidiarrheal medication that works by slowing down gut movement. However, if the diarrhea is caused by an infection, such as from spoiled food, it is important to allow the body to expel the infectious agents. Using loperamide in such cases can prolong the infection and potentially worsen the condition.
Choice B Reason:
You can take loperamide until the diarrhea stops is incorrect. While loperamide can be effective for non-infectious diarrhea, it is not recommended for infectious diarrhea. Stopping the diarrhea prematurely can trap the infectious agents in the intestines, leading to more severe symptoms.
Choice C Reason:
Loperamide has no side effects is incorrect. Loperamide can have side effects, including constipation, dizziness, and abdominal pain. It is important to use this medication under the guidance of a healthcare provider, especially in cases of infectious diarrhea.
Choice D Reason:
Loperamide should not stop this type of diarrhea is incorrect. While it is true that loperamide should not be used for infectious diarrhea, the statement is misleading. Loperamide can stop diarrhea, but it is not appropriate for all types of diarrhea, particularly those caused by infections.
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