Question

The nurse is developing a nursing care plan for a client diagnosed with CHF. A nursing diagnosis of "decrease cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? The client will:

a. Be able to ambulate in the hall by the date of discharge.
b. Have an audible S1 and S2 with not S3 heard by the end of shift.
c. Turn, cough, and deep breathe every 2 hours.
d. Have a pulse ox reading of 98% by day two of care.

Answer 1

The best short-term goal for a client diagnosed with CHF would be to have an audible S1 and S2 with no S3 heard by the end of the shift.

Step-by-step explanation:

The short-term goal that would be best for the client diagnosed with CHF would be option b. Have an audible S1 and S2 with no S3 heard by the end of the shift.

Decreased cardiac output is a common problem in clients diagnosed with CHF. S1 and S2 refer to the first and second heart sounds that are normally heard during a cardiac examination. S3, on the other hand, is an abnormal extra heart sound that can indicate fluid overload and decreased cardiac output.

By having an audible S1 and S2 with no S3 heard, it indicates that the client's heart is functioning more effectively and pumping blood adequately. This goal focuses on improving the client's cardiac output, which is the main issue in CHF.