A patient with acute decompensated heart failure has been prescribed intravenous diuretic medications to control fluid and congestion. Which nursing intervention would the nurse need to perform in order to best monitor fluid and electrolyte balance in this patient?

 

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Correct

- Check the patient's weight daily

- Insert a Foley catheter

- Monitor for signs of pancreatic dysfunction

- Administer pain medications as ordered

Rationale

"Check the patient's weight daily" is correct. Decompensated heart failure can cause a patient to experience fluid overload, leading to difficulties with breathing and increased amounts of fluid in peripheral tissues (edema). In this case the nurse should weigh the patient daily and record it. If the patient is retaining fluid, he will gain weight.

"Insert a Foley catheter" is incorrect because this does not give a complete picture of a gain or loss of fluid balance over time.

"Monitor for signs of pancreatic dysfunction" is incorrect because information about pancreatic dysfunction does not help to monitor fluid and electrolyte balance.

"Administer pain medications as ordered" is incorrect because pain control, while a very important part of nursing care, is not related to fluid and electrolyte balance.

References:
Sheppard, M. (2001, February 8). Assessing fluid balance. Retrieved from https://www.nursingtimes.net/clinical-archive/assessment-skills/assessing-fluid-balance/206162.article

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