A patient with chronic heart failure gains 2 kilograms over two days and reports increasing shortness of breath. Which action should the nurse take?
Correct answer: B. Report the findings because they suggest fluid retention
- A. Document the gain as an expected response to treatment
- B. Report the findings because they suggest fluid retention
- C. Encourage extra fluids to prevent dehydration
- D. Ask the patient to skip the prescribed diuretic dose
Explanation
A rapid weight gain of about 2 kilograms suggests fluid accumulation and worsening heart failure, especially with dyspnoea. The diuretic should not be stopped without an order, and extra fluids may increase congestion.
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About Cardiovascular Nursing
Covers assessment and nursing care for hypertension, coronary artery disease, angina, myocardial infarction, heart failure, valvular disease and dysrhythmias. It includes interpreting vital signs and ECG findings, managing chest pain, monitoring cardiac medicines, recognizing complications and distinguishing left-sided from right-sided heart failure.
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