A nurse cares for a client with right-sided heart failure. The ...

[erika]

A nurse cares for a client with right-sided heart failure. The client asks, Why do I need to weigh myself every day? How should the nurse respond?
 
  a. Weight is the best indication that you are gaining or losing fluid.
  b. Daily weights will help us make sure that you're eating properly.
  c. The hospital requires that all inpatients be weighed daily.
  d. You need to lose weight to decrease the incidence of heart failure.

Question 2

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next?
 
  a. Assess for symptoms of left-sided heart failure.
  b. Document this as a normal finding.
  c. Call the health care provider immediately.
  d. Transfer the client to the intensive care unit.

[alexanderhamilton]

Answer to Question 1

ANS: A
Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals 2.2 pounds. The other responses do not address the importance of monitoring fluid retention or loss.

Answer to Question 2

ANS: A
The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.

[erika]

Thank you

[alexanderhamilton]

No problemo