The nurse is assessing fluid balance in the client with heart failure. Which of these strategies will the nurse employ?*1 pointa. Ask the client how much fluid was consumed yesterday.b. Place an indwelling catheter to measure urine output.c. Auscultate the lungs for adventitious sounds.d. Weigh the client daily, at the same time.

A client has been diagnosed with overhydration and is confused. Which intervention does the nurse include in the client's plan of care to relieve the confusion?*1 pointa. Measuring intake and output every shiftb. Slowing the IV flow rate to 50 mL/hrc. Administering diuretic agents as prescribedd. Placing the client in Trendelenburg position

The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority?*1 pointa. Document the observation in the chart.b. Measure urine specific gravity and volume.c. Assess the pulse and blood pressure.d. Assess the client's deep tendon reflexes.

A nurse is caring for a client immediately following a cardiac catheterization through the right femoral artery. Which of the following actions should the nurse take?A. Monitor the client's vital signs once every hour.B. Elevate the head of the client's bed to a 45° angle.C. Restrict the client's fluid intake.D. Instruct the client not to bend the affected leg.

A nurse is assessing a client who has heart failure.Which of the following client statements should indicate to the nurse that the client needs a referral for cardiac rehabilitation?A. "I will weigh myself daily.".B. "l hate how I feel all the time.".C. "I'm too tired to brush my teeth.".D. "I need to start eating a low-sodium diet.

The nurse performs a physical assessment on a client and observes the client demonstrate palmar flexion while obtaining the blood pressure. The nurse should take which action?A. Obtain the blood pressure on the client's calfB. Request an order for a magnesium levelC. Assess the client's orthostatic blood pressureD. Obtain capillary blood glucose (CBG)