Difficulty: Medium
Average Score: 77%
Simulated
A 6-year-old with heart failure (HF) gained 2 pounds (0.9 kg) in the last 24 hours. Which intervention is most important for the nurse to implement?
Correct answer
B
Rationale
Assessing bilateral lung sounds is critical as sudden weight gain in heart failure may indicate fluid retention, potentially causing pulmonary edema, which requires immediate attention.