What findings identified by the nurse on an assessment of a patient being treated for heart failure would cause the nurse to notify the patient's health care provider that the patient's status was deteriorating? Note: Credit will be given

Question

only if all correct choices and no incorrect choices are selected. Select all that apply. 1. S3 and S4 heart sounds
2. Oxygen saturation 80% on 4 liters oxygen nasal cannula
3. Urine output 10 mL over the last hour
4. Onset of production cough
5. Weight loss of 3 lbs from previous weight

Answer 1

1,2,3,4
Rationale 1: S3 and S4 heart sounds indicate the patient's cardiac status is deteriorating.
Rationale 2: Reduced oxygen saturation is an indication that the patient's pulmonary status is deteriorating.
Rationale 3: Poor urine output is an indication that the patient's systemic status is deteriorating.
Rationale 4: Worsening cough is an indication that the patient's pulmonary status is deteriorating.
Rationale 5: Weight loss is not an indication that the patient's health status is deteriorating.