A patient is in the hospital with heart failure. The nurse notes during the evening assessment that the patient's neck veins are distended and the patient has dyspnea. What action should the nurse take?
A) Place the patient in low Fowler's and notify the physician.
B) Increase the patient's IV fluid and auscultate the lungs.
C) Place the patient in semi-Fowler's and prepare to give the PRN diuretic as ordered.
D) Discontinue the patient's IV.
Ans: C
Feedback: The patient is exhibiting signs of fluid overload and should be placed in a semi-Fowler's position; diuretics should be given as ordered.
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