A nurse teaches a client who has a history of heart failure. ...

[EY67]

A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this client's discharge teaching?
 
  a. Avoid drinking more than 3 quarts of liquids each day.
  b. Eat six small meals daily instead of three larger meals.
  c. When you feel short of breath, take an additional diuretic.
  d. Weigh yourself daily while wearing the same amount of clothing.

Question 2

A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?
 
  a. Assess the client's respiratory status.
  b. Draw blood to assess the client's serum electrolytes.
  c. Administer intravenous furosemide (Lasix).
  d. Ask the client about current medications.

[Chou]

Answer to Question 1

ANS: D
Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of heart failure. The client should be taught to eat a heart-healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.

Answer to Question 2

ANS: A
Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take priority over assessing respiratory status.

[EY67]

Excellent

[LVPMS]

Gracias!