The nurse is assessing a client being treated for congestive heart failure (CHF). Which physical findings would indicate that the client's condition is not improving?
Select all that apply.
A) Urine output 160 ml over 8 hours
B) Pulse oximetry reading of 96%
C) Temperature of 98.6 °F (37 °C)
D) Wheezing of breath sounds in all lobes
E) Moderate amount of clear, thin mucus
Answer: A, D
Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic in congestive heart failure. These sounds would indicate that the client's condition is not improving. A urine output of less than 30 ml/hour should be reported to the healthcare provider and is an indication of a worsening of congestive heart failure. A temperature reading of 98.6 °F, moderate clear mucus, and a pulse oximetry reading of 96% are all normal findings.
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