Final answer:
Nursing interventions for a patient with heart failure exacerbation prescribed an IV loop diuretic include (A) performing daily weights, (C) strict intake and output monitoring, and (E) assessing lung sounds every shift, but not a low potassium diet or encouraging high fluid intake without considering potential restrictions.
Step-by-step explanation:
When developing a plan of care for a patient with fluid volume overload related to heart failure exacerbation and has been prescribed an IV loop diuretic, several nursing interventions are essential:
- A. Perform and assess daily weights. This is crucial to monitor the patient's fluid status and effectiveness of the diuretic therapy.
- C. Strict measuring of the patient's daily intake and output. This includes all fluids ingested and excreted to ensure the patient is losing fluid volume as expected.
- E. Assess lung sounds every shift. This is important to evaluate for pulmonary edema, a common issue in heart failure that can be exacerbated by fluid overload.
However, educating the patient about consuming a low potassium diet (option B) is incorrect as loop diuretics can cause potassium loss, making it necessary to monitor for hypokalemia and possibly supplement potassium.
Encouraging the patient to drink 2 L of fluids per day (option D) might not be appropriate as fluid restrictions are often necessary in fluid volume overload. Loop diuretics work by inhibiting the reabsorption of Na+ and Cl- in the loop of Henle, which increases urine production and thus reduces fluid volume.