A nurse is caring for a client admitted with heart failure who is experiencing increased shortness of breath. The nurse notes the client has gained 3 pounds in 24 hours, reports feeling fatigued, and has crackles in both lungs upon auscultation. Which action should the nurse take to update the client’s plan of care?
Recheck the client’s weight in 12 hours to confirm if the gain continues.
Document the findings in the client’s medical record and continue to monitor the client.
Advise the client to independently reduce fluid intake to address weight gain.
Notify the healthcare provider and suggest adjusting the client’s diuretic therapy.
The correct answer is to notify the healthcare provider and suggest adjusting the client’s diuretic therapy. This action addresses the client’s acute symptoms, which indicate fluid overload—a common complication in clients with heart failure. By collaborating with the healthcare provider to modify the client’s medication regimen, the nurse ensures that the plan of care evolves to meet the client’s current needs. The other options are incorrect because they focus on either documenting findings without intervening, offering nontherapeutic suggestions like recommending independent fluid restrictions, or delaying action by rechecking weight later rather than addressing the acute issue.
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