Medical Surgical Heart failure #6

Question

The nurse is providing discharge education on fluid balance monitoring to a client with a new diagnosis of right-sided heart failure. The nurse will stress which priority instruction for monitoring fluid balance?

Answers

  1. Weigh daily at the same time in similar clothing
    • Rationale:

      This answer is correct because right-sided heart failure (HF) occurs as a result of inefficient pumping of the right side of the heart, causing fluid buildup in the abdomen, face/neck, legs, and feet. Fluid backs up into the body because the right side of the heart is not pumping efficiently. Excessive fluid causes weight gain, distended neck veins or jugular vein distention (JVD), and swelling of the liver. Therefore, the client should be taught to weigh themselves daily at the same time in similar clothing to monitor HF. Weight gain of 2-3 pounds a day or 5 pounds over the client’s baseline should be reported to the healthcare provider.

  2. Take self-pulse rates and report findings below 60
    • Rationale:

      This answer is not correct because teaching taking self-pulses and reporting findings below 60 is related to taking digoxin, not priority instruction for monitoring fluid balance. The client should be taught to weigh themselves daily at the same time in similar clothing to monitor HF. Weight gain of 2-3 pounds a day or 5 pounds over the client’s baseline should be reported to the healthcare provider.

  3. Take blood pressure at the same time daily
    • Rationale:

      This answer is not correct because teaching the client about taking blood pressure at the same time daily is not the priority instruction for monitoring fluid balance. The client should be taught to weigh themselves daily at the same time in similar clothing to monitor HF. Weight gain of 2-3 pounds a day or 5 pounds over the client’s baseline should be reported to the healthcare provider.

  4. Bowel movements should be logged
    • Rationale:

      This answer is not correct because monitoring bowel movements is not the priority instruction for monitoring fluid balance. The client should be taught to weigh themselves daily at the same time in similar clothing to monitor HF. Weight gain of 2-3 pounds a day or 5 pounds over the client’s baseline should be reported to the healthcare provider.

Overview

Right-sided heart failure (HF) causes fluid buildup in the abdomen, face/neck, legs, and feet, causing weight gain, therefore, the client should be taught to weigh themselves daily at the same time in similar clothing to monitor HF. Weight gain of 2-3 pounds a day or 5 pounds over the client’s baseline should be reported to the healthcare provider.

Explanation

Learning Outcomes

Right-sided heart failure (HF) occurs as a result of inefficient pumping of the right side of the heart, causing fluid buildup in the abdomen, face/neck, legs, and feet. Fluid backs up into the body because the right side of the heart is not pumping efficiently. Excessive fluid causes weight gain, distended neck veins or jugular vein distention (JVD), and swelling of the liver. Therefore, the client should be taught to weigh themselves daily at the same time in similar clothing to monitor HF. Weight gain of 2-3 pounds a day or 5 pounds over the client’s baseline should be reported to the healthcare provider. Left-sided heart failure is most associated with pulmonary symptoms which include pulmonary edema, dry, hacking cough, paroxysmal nocturnal dyspnea, and exertional dyspnea, and orthopnea.

Test Taking Tip

Be sure to read the question. All the answers may address some of the information in the question, but only one answers the question best.

Video Rationale