Difficulty: Medium
Average Score: 65%
Simulated
A client with heart failure reports weight gain of 3 pounds in 2 days. What should the nurse do first?
Correct answer
A
Rationale
The correct answer is A: Assess for edema. Weight gain in heart failure can indicate fluid retention, potentially leading to worsening heart failure. Assessing for edema will help determine the extent of fluid retention and guide appropriate interventions. Increasing diuretic dose (B) without assessing for edema may lead to dehydration. Restricting fluid intake (C) and encouraging low-sodium diet (D) are important interventions but should be based on assessment findings.