Which action(s) will the nurse take when caring for a patient with heart failure? (Select all that apply.)
a. Administer diuretics at bedtime.
b. Assess electrolyte levels.
c. Report daily weight fluctuations.
d. Encourage sodium intake.
e. Maintain skin hygiene.
ANS: B, C, E
Ongoing assessment of electrolyte levels is critical when caring for a patient with heart failure. Weight gains and losses are the single best indicator of fluid gain or loss. The maintenance of skin care and changing of positions are essential to prevent skin breakdown. Diuretics should be given in the morning and afternoon, not at bedtime, because this would interfere with sleep. Heart failure patients are prone to edema, which interferes with vascular return in the peripheral areas. Sodium restriction is one way of controlling edema.
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