Congestive Cardiac Failure

Congestive Cardiac Failure ( 35 Questions)

Question 1 :
A nurse is caring for a client with congestive heart failure who reports sudden weight gain, shortness of breath, and swelling in the ankles. What is the nurse's priority action?


Correct Answer: C

A) This choice is incorrect because sudden weight gain, shortness of breath, and ankle swelling are not normal with CHF and may indicate worsening of the condition. The nurse should not reassure the client but rather take appropriate action to address the symptoms.

B) This choice is incorrect because the client's symptoms suggest fluid retention, and increasing fluid intake would exacerbate the condition. The nurse should not encourage the client to increase fluid intake without consulting the healthcare provider.

C) This choice is correct. The client's sudden weight gain, shortness of breath, and ankle swelling are signs of worsening congestive heart failure. The nurse's priority action is to notify the healthcare provider immediately to address the client's worsening condition and adjust the treatment plan as needed.

D) This choice is incorrect because administering a diuretic is not within the nurse's scope of practice without a healthcare provider's order. The nurse should first notify the healthcare provider to evaluate the client's condition and determine the appropriate intervention.


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