The nurse is assessing a client with heart failure. Which assessment data are the best indicator of fluid balance?
Generalized edema in the lower extremities
Urine output 200mL in the last 4 hours
Weight increase of 9lbs in the last week
✓
BP 144/79 mmHg
Correct Answer
Weight increase of 9lbs in the last week
A sudden weight increase of 2.2 pounds can result from excess fluid in the interstitial spaces. The best indicator of fluid balances weight. A weight increase of 9 pounds in the past week is a significant indicator of fluid balance as weight often increases first, allowing for intervention before other symptoms, such as a edema develop.
Question 2
A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left sided heart failure?
A 42-year-old man with pulmonary hypertension
A 36-year-old woman with aortic stenosis
✓
A 59-year-old woman who smokes cigarettes daily
A 70-year-old man who had a cerebral vascular incident
Correct Answer
A 36-year-old woman with aortic stenosis
Although most people with heart failure will have failure that progresses from left to right, it is possible to have left sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.
Question 3
A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left sided heart failure?
I must stop halfway up the stairs to catch my breath 
✓
I have been drinking more water than usual
I have experienced blurry vision on several occasions
I am awakened by the need to urinate at night 
Correct Answer
I must stop halfway up the stairs to catch my breath 
Clients with left sided heart, failure, report, weakness, or fatigue, while performing normal activities of daily living, as well as difficulty breathing, or catching their breath. This occurs as fluid moves into the alveoli. Nocturia is often seen with right sided heart failure. Thirst and blurred vision are not related to heart failure.