A patient is suffering from fluid overload due to a history of severe liver disease. Which of the following interventions would be the highest priority for this patient?

 

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Correct

- Monitor for heart arrhythmias and the presence of crackles on auscultation

- Weigh the patient daily

- Elevate the lower extremities to reduce edema

- Check skin regularly for signs of skin breakdown

Rationale

Fluid overload can develop as a result of various types of disease processes; it can lead to edema, weight gain, and electrolyte imbalance. To avoid complications of fluid overload, the nurse should listen to the patients heart rate to determine if excess fluid has caused heart arrhythmias; the nurse should also listen to the patients breath sounds for signs of breathing difficulties because of increased fluid.

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