When the nurse weighs an edematous patient with congestive heart failure, the weight increase from yesterday is 2.2 lb. What would be included in the plan of care for the patient? (Select all that apply.)
a. Keep a pitcher of water at the bedside.
b. Offer frequent oral hygiene.
c. Limit fresh fruits and vegetables.
d. Avoid changing the patient's position.
e. Provide hard candy.
ANS: B, C, E
The weight gain of 2.2 lb (1 kg) is significant and would signify fluid retention. Fluid restrictions would be expected. Frequent oral hygiene is a comfort measure to combat dry mucous membranes caused by fluid restriction. Fresh fruits and vegetables are high in water content and should be avoided. Hard candy would stimulate the production of saliva. Water should not be kept at the beside of a patient with fluid restrictions. The patient's position should be changed frequently to prevent skin breakdown.
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