While teaching a client with new-onset right-sided heart failure, the nurse should educate the client to monitor for fluid accumulation by:
A) Weighing every day at the same time with same type of clothing
B) Measuring all of the client's urine output daily to check for a decrease in output
C) Listening to the breath sound with a stethoscope every morning
D) Take blood pressure daily and call doctor if it is decreased
Ans: A
Feedback:
When the right heart fails, a damming back of blood occurs, leading to its accumulation in the systemic venous system, causing an increase in right atrial, right ventricular end-diastolic, and systemic venous pressures. The accumulation of fluid (edema) is evidenced by a gain in weight (i.e., 1 pint of accumulated fluid results in a 1-pound weight gain). Shortness of breath due to congestion of the pulmonary circulation is one of the major manifestations of left-sided heart failure. It is unrealistic to expect clients to listen to their own breath sounds. BP measurement could be an intervention; however, it is not a primary indicator of edema from right-sided heart failure. With impairment of left heart function, there is a decrease in cardiac output, with resulting decreased renal perfusion and output.
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