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?

A. Administer aspirin:

Aspirin is commonly given to patients suspected of having a heart attack because it helps to inhibit platelet aggregation and reduce the risk of further clot formation. However, the administration of aspirin typically follows the confirmation of a cardiac event through diagnostic tests like the ECG. Aspirin is not the initial priority compared to obtaining diagnostic data.

B. 12 Lead Electrocardiography (ECG):

This is the most critical and time-sensitive action because it helps to quickly assess the patient's cardiac status. A 12 Lead ECG can identify important findings such as ST-segment elevation or depression, which are indicative of acute myocardial infarction (heart attack) or other cardiac abnormalities. Early detection and intervention are crucial in improving outcomes for patients with suspected cardiac events.

C. Assess vital signs:

Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, provide valuable information about the patient's overall condition and can help determine the severity of the cardiac event. While assessing vital signs is important, performing the ECG takes precedence due to its immediate relevance in diagnosing and managing a potential cardiac emergency.

D. Administer morphine:

Morphine may be indicated for pain relief in patients with acute coronary syndromes. However, its administration should be based on the patient's pain level, hemodynamic stability, and other factors assessed after obtaining the ECG and vital signs. Morphine administration is not the primary action within the first 10 minutes of the patient's arrival; it follows the initial assessment and diagnostic procedures.

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.