A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE) inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days
The nurse's priority action will be to
a. have the patient recall the dietary intake for the last 3 days.
b. ask the patient about the use of the prescribed medications.
c. assess the patient for clinical manifestations of acute heart failure.
d. teach the patient about the importance of restricting dietary sodium.
ANS: C
The 5-pound weight gain over 3 days indicates that the patient's chronic heart failure may be worsening. It is important that the patient be assessed immediately for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.
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