Question

You're developing a plan of care for a patient with fluid volume overload related to heart failure exacerbation. The physician has prescribed an IV loop diuretic. What nursing interventions will you include in the patient's plan of care? Select all that apply:*

A. Perform and assess daily weights.
B. Educate the patient about consuming a low potassium diet.
C. Strict measuring of the patient's daily intake and output.
D. Encourage the patient to drink 2 L of fluids per day.
E. Assess lung sounds every shift.

Answer 1

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.