ATI PN Adult Medical Surgical 2020 with NGN
ATI PN Adult Medical Surgical 2020 with NGN ( 78 Questions)
A nurse is contributing to the plan of care for a client who has heart failure. Which of the following actions should the nurse include in the plan?
reason: Obtaining weight weekly is not sufficient for monitoring fluid status in a client who has heart failure. The nurse should obtain weight daily at the same time using the same scale and compare it with the baseline weight. A weight gain of more than 2 kg (4.4 lb) in a week or more than 1 kg (2.2 lb) in a day indicates fluid retention and worsening heart failure.
reason: Measuring vital signs every 8 hr may not be frequent enough for detecting changes in a client who has heart failure. The nurse should measure vital signs at least every 4 hr or more often as needed based on the client's condition and response to treatment. Vital signs may indicate hypoxia, tachycardia, hypotension, or other signs of shock.
reason: Allowing frequent rest periods is an appropriate action for a client who has heart failure. Rest periods reduce oxygen demand and cardiac workload and prevent fatigue and dyspnea. The nurse should schedule rest periods between activities and provide assistance as needed.
reason: Encouraging fluids is not advisable for a client who has heart failure. Fluid intake should be restricted to prevent fluid overload and pulmonary edema. The nurse should monitor the client's fluid intake and output, assess for signs of fluid retention, and educate the client about limiting sodium and fluid intake.
Choice A reason: Obtaining weight weekly is not sufficient for monitoring fluid status in a client who has heart failure. The nurse should obtain weight daily at the same time using the same scale and compare it with the baseline weight. A weight gain of more than 2 kg (4.4 lb) in a week or more than 1 kg (2.2 lb) in a day indicates fluid retention and worsening heart failure.
Choice B reason: Measuring vital signs every 8 hr may not be frequent enough for detecting changes in a client who has heart failure. The nurse should measure vital signs at least every 4 hr or more often as needed based on the client's condition and response to treatment. Vital signs may indicate hypoxia, tachycardia, hypotension, or other signs of shock.
Choice C reason: Allowing frequent rest periods is an appropriate action for a client who has heart failure. Rest periods reduce oxygen demand and cardiac workload and prevent fatigue and dyspnea. The nurse should schedule rest periods between activities and provide assistance as needed.
Choice D reason: Encouraging fluids is not advisable for a client who has heart failure. Fluid intake should be restricted to prevent fluid overload and pulmonary edema. The nurse should monitor the client's fluid intake and output, assess for signs of fluid retention, and educate the client about limiting sodium and fluid intake.