A patient with chronic heart failure who is taking a diuretic and an angiotensin-converting enzyme (ACE)inhibitor and who is on a low-sodium diet tells the home health nurse about a 5-lb weight gain in the past 3 days. The nurse's priority action will be to

Question

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The 5-lb weight gain over 3 days indicates that the patient's chronic heart failure may be worsening. It is important that the patient be assessed immediately for other clinical manifestations of decompensation,such as lung crackles. A dietary recall to detect hidden sodium in the diet,reinforcement of sodium restrictions,and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated.

A Patient with Chronic Heart Failure Who Is Taking a Diuretic