2024 PN NCLEX Questions Nursing Practice Question
A 64 year-old male who has been diagnosed with COPD and CHF exhibits an increase in total body weight of 10 lbs. over the last few days. The nurse should:
Correct Answer: B
Rationale: Monitoring the intake and output (I&O) is crucial for assessing fluid balance, particularly in patients with COPD and CHF, as weight gain often indicates fluid retention. This option allows for a comprehensive understanding of the patient's fluid status.
Contacting the physician immediately (Option A) may be premature without further assessment. Encouraging ambulation (Option C) might not be appropriate if the patient is experiencing significant edema or respiratory distress. Checking vital signs every 2 hours (Option D) is important but does not directly address the immediate concern of weight gain and fluid retention.