Question

A client with a history of heart failure on daily weights has a 2-pound (0.9 kilogram) weight gain and pitting edema in lower extremities bilaterally. which action should the nurse take next

Answer 1

The nurse should perform a head-to-toe assessment, including vital signs.

Head-to-toe is a physical examination of patient’s condition usually done in order to check appearance or general status of the patient. It includes observation of as vital signs, head, ears, eyes, nose, throat , neck , respiratory and cardiac check , abdomen , pulses , extremities , skin , neurological check.