A nurse is caring for a 72-year-old client with heart failure who reports a sudden weight gain of 3 lbs within 24 hours and new-onset shortness of breath. What is the best action for the nurse to take to address these findings and update the client’s care plan?
Encourage the client to rest and note if symptoms improve before implementing changes.
Reinforce client education on maintaining sodium restrictions and fluid intake.
Document the findings and increase the frequency of monitoring the client's weight and vital signs.
Assess for additional signs of fluid overload and communicate findings to the healthcare provider.
The correct answer is to assess for additional evidence of fluid overload, such as lung sounds or peripheral edema, and report findings to the healthcare provider for further evaluation. These symptoms may indicate worsening heart failure, and understanding the full clinical picture is critical for adjusting the plan of care appropriately. While ensuring adherence to dietary restrictions and educating the client are important, these actions do not directly address the potential acute condition. Similarly, increasing monitoring frequency does not intervene to prevent worsening symptoms or complications.
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