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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The test is noninvasive, and nothing will be inserted into the client's body: Transthoracic echocardiography (TTE) is a noninvasive procedure that uses ultrasound waves to create images of the heart. It involves placing a transducer on the chest wall to capture images of the heart's structure and function. The nurse should inform the client that no instruments or devices will be inserted into their body during the test.
B. The client will remain on bed rest for 1 to 2 hours after the test: This statement is not typically accurate for a TTE procedure. After a TTE, clients can usually resume their normal activities without any specific bed rest requirements, unless otherwise specified by the healthcare provider based on individual circumstances.
C. The client's pain will be managed aggressively during the procedure: TTE is generally a painless procedure that does not require aggressive pain management. The client may feel slight discomfort from the transducer's pressure on the chest, but it is typically well tolerated without the need for pain medication.
D. The test will provide a detailed profile of the heart's electrical activity: While echocardiography provides detailed images of the heart's structure and function, including information about blood flow and valve function, it does not directly assess the heart's electrical activity. For evaluating electrical activity, other tests such as electrocardiography (ECG or EKG) would be used.
Correct Answer is B
Explanation
A. The blood was infused too quickly and overwhelmed the client's circulatory system:
While infusing blood too quickly can lead to circulatory overload and related complications like heart failure or pulmonary edema, it is not the cause of an acute hemolytic transfusion reaction. Acute hemolytic reactions occur due to immune responses against incompatible donor blood.
B. The donor blood was incompatible with that of the client:
This is the correct answer. An acute hemolytic transfusion reaction happens when there is an incompatibility between the donor's blood and the recipient's blood. This can occur due to mismatched ABO blood types or Rh factor, leading to the recipient's immune system attacking and destroying the transfused red blood cells.
C. The client had a sensitivity reaction to a plasma protein in the blood:
Sensitivity reactions to plasma proteins can occur, but they typically result in different types of transfusion reactions, such as allergic reactions or febrile non-hemolytic reactions. These reactions are caused by antibodies to specific plasma proteins and are not the cause of acute hemolytic transfusion reactions.
D. Antibodies to donor leukocytes remained in the blood:
This option refers to febrile non-hemolytic transfusion reactions, which occur due to antibodies against donor leukocytes. However, this type of reaction is distinct from acute hemolytic reactions, which are primarily caused by ABO or Rh incompatibility.
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