A home care nurse is instructing a client diagnosed with congestive heart failure on daily self-monitoring between home care visits. The nurse should instruct the client to monitor and record which items?

Question

Standard Text: Select all that apply.
1. Weight
2. Pulse
3. Temperature
4. Blood pressure
5. Respiratory rate

Answer 1

Correct Answer: 1,2,4
Rationale 1: It is essential that the client measure and record weight daily to monitor for fluid loss or retention.
Rationale 2: It is essential that the client measure and record the pulse daily to determine the effectiveness of the medication therapy.
Rationale 3: There is no need for the client to measure and record a daily temperature while taking a diuretic.
Rationale 4: It is essential that the client measure and record daily blood pressure to determine the effectiveness of the medication therapy.
Rationale 5: There is no need for the client to measure and record a daily respiratory rate while taking a diuretic.
Global Rationale: It is essential that the client measure and record weight, pulse, and blood pressure daily to monitor for fluid loss or retention. There is no need for the client to measure and record a daily temperature or respiratory rates while taking a diuretic.