The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting?

Monitor weight daily

Assess radial pulses daily

Monitor bowel movements

Monitor blood pressure daily

Answer and Explanation

The Correct Answer is A

A. Monitor weight daily: Daily weight monitoring is a crucial aspect of assessing fluid balance in clients with heart failure. Sudden weight gain can indicate fluid retention, which may be a sign of worsening heart failure. The nurse should instruct the client to weigh themselves at the same time each day, preferably in the morning after emptying the bladder and before eating breakfast, and to report any significant weight changes to their healthcare provider.

B. Assess radial pulses daily: While assessing radial pulses is important for monitoring cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Radial pulse assessment is more related to evaluating cardiac output and peripheral perfusion.

C. Monitor bowel movements: Monitoring bowel movements is not directly related to assessing fluid balance in heart failure. Although changes in bowel habits can sometimes be associated with fluid and electrolyte imbalances, it is not the primary method for assessing fluid balance in this context.

D. Monitor blood pressure daily: While monitoring blood pressure is important for managing hypertension and evaluating cardiovascular status, it is not specifically focused on assessing fluid balance in heart failure. Blood pressure monitoring is more related to assessing hemodynamic stability and response to medications.

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Correct Answer is C

Explanation

A. Initiate cardiopulmonary resuscitation (CPR): CPR is not indicated in this scenario unless the client experiences a cardiac arrest. Chest pain during an exercise stress test does not automatically warrant CPR.

B. Administer sublingual nitroglycerin to allow the client to finish the test: Nitroglycerin is typically used to relieve angina (chest pain) associated with myocardial ischemia. However, in this case, the exercise stress test should be stopped to evaluate the cause of the chest pain before administering nitroglycerin.

C. Stop the test and monitor the client closely: This is the correct action. Chest pain during an exercise stress test may indicate myocardial ischemia (lack of blood flow to the heart muscle), and stopping the test allows for further assessment and evaluation of the client's condition.

D. Administer analgesia and slow the test: Administering analgesia (pain medication) is not appropriate without first determining the cause of the chest pain. Slowing the test may not address the underlying issue and could potentially worsen the client's condition if they are experiencing cardiac-related chest pain.

A. I will wear layered clothing when walking outside in winter. B. I will walk early in the morning when it is hot outside. C. If I get shortness of breath, I should slow down a bit. D. My exercise intensity should not exceed my ability to talk.

Correct Answer is B

Explanation

A. "I will wear layered clothing when walking outside in winter": This statement shows an understanding of the need to dress appropriately for weather conditions, which is important in managing symptoms during physical activity.

B. "I will walk early in the morning when it is hot outside": This statement indicates a lack of understanding regarding the ideal timing for outdoor activities, especially in hot weather. Exercising during the cooler parts of the day (such as early morning or late evening) is recommended to avoid heat-related stress and potential exacerbation of cardiovascular symptoms.

C. "If I get shortness of breath, I should slow down a bit": This statement demonstrates an understanding of monitoring symptoms during exercise and adjusting activity levels accordingly, which is an important aspect of managing coronary artery disease.

D. "My exercise intensity should not exceed my ability to talk": This statement reflects an understanding of the recommended exercise intensity level based on the ability to talk comfortably during physical activity, known as the "talk test."

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The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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