A home care nurse is instructing a patient with congestive heart failure on daily self-monitoring between home care visits. The nurse should instruct the patient to monitor and record
1. weight.
2. pulse.
3. temperature.
4. blood pressure.
5. respiratory rate.
1,2,4
Rationale 1: It is essential that the patient measure and record weight daily to monitor for fluid loss or retention.
Rationale 2: It is essential that the patient measure and record the pulse daily to determine the effectiveness of the medication therapy.
Rationale 3: There is no need for the patient to measure and record a daily temperature while taking a diuretic.
Rationale 4: It is essential that the patient measure and record daily blood pressure to determine the effectiveness of the medication therapy.
Rationale 5: There is no need for the patient to measure and record a daily respiratory rate while taking a diuretic.
Global Rationale: It is essential that the patient measure and record weight daily to monitor for fluid loss or retention. It is essential that the patient measure and record the pulse daily to determine the effectiveness of the medication therapy. It is essential that the patient measure and record daily blood pressure to determine the effectiveness of the medication therapy. There is no need for the patient to measure and record a daily temperature while taking a diuretic. There is no need for the patient to measure and record a daily respiratory rate while taking a diuretic.
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