A patient with chronic heart failure who has prescriptions for a diuretic, an ACE-inhibitor, and a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurse's first action will be to

Question

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The 5-pound weight gain over 3 days indicates that the patient's chronic heart failure may be worsening. It is important that the patient be immediately assessed 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 Has Prescriptions for a Diuretic