The nurse is caring for a patient who has a history of congestive heart failure. The nurse includes the diagnosis fluid volume excess in the patient's care plan. Which goal statement has the highest priority for the patient and nurse?
a. The patient's lung sounds will remain clear.
b. The patient will have urine output of at least 30 mL/hr.
c. The patient will verbalize understanding of fluid restrictions.
d. The patient's pitting pedal edema will resolve within 72 hours.
ANS: A
Oxygenation is the highest priority for the patient with congestive heart failure and fluid volume excess. Keeping the patient's lungs clear is the most important goal for the nurse to consider when caring for this patient.
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