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-pound weight gain in the last 3 days.The nurse's priority action will be to

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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 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