The nurse is caring for a client who is receiving IV furosemide and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. When evaluating the client response to the medications, which of the following is the best indicator that the treatment has been effective?
A)Weight loss of 1 kg overnight
B)Hourly urine output greater than 60 mL
C)Reduction in client complaints of chest pain
D)Decreased dyspnea with the head of bed at 30 degrees

Question

Quizplus · Accepted Answer

Because the client's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occurred but are not as specific to evaluating this client's response.

The Nurse Is Caring for a Client Who Is Receiving