A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time?Select all that apply.*1 pointa. Place the client on bed rest.b. Evaluate the electrolyte levels.c. Administer the ordered diuretic.d. assess for orthostatic hypotension.e. initiate cardiac monitoring
Question
A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time?Select all that apply.*1 pointa. Place the client on bed rest.b. Evaluate the electrolyte levels.c. Administer the ordered diuretic.d. assess for orthostatic hypotension.e. initiate cardiac monitoring
Solution
The nursing actions that are indicated at this time include:
a. Place the client on bed rest: This is important to conserve the client's energy and prevent further complications such as falls due to weakness or dizziness.
b. Evaluate the electrolyte levels: Diarrhea can cause significant loss of electrolytes, which can be exacerbated by the use of diuretics. It's important to assess the client's electrolyte levels to identify any imbalances that need to be addressed.
d. Assess for orthostatic hypotension: This condition, which is a form of low blood pressure that happens when you stand up from sitting or lying down, can be a side effect of both dehydration (from the diarrhea and poor oral intake) and the use of diuretics.
e. Initiate cardiac monitoring: Given the client's history of congestive heart failure and the current health issues, continuous cardiac monitoring is necessary to promptly detect any changes in heart rhythm or rate that could indicate worsening of the heart failure.
Administering the ordered diuretic (option c) may not be appropriate at this time, given the client's dehydration status. This decision, however, should be based on a thorough assessment and consultation with the healthcare provider.
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