Difficulty: Medium
Average Score: 89%
Full-length
A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action?
Correct answer
C
Rationale
Low urine output (200 mL/8 hr) in heart failure suggests worsening fluid retention, requiring immediate reporting to the RN (C). Auscultation (A), fluids (B), and IV diuretics (D) require RN direction.