Clinical Nurse Leader Practice Exam

What is the key nursing intervention for monitoring a patient with congestive heart failure (CHF)?

1. Assessing the patient's knowledge of the disease

2. Encouraging coughing and deep breathing

3. Encouraging frequent ambulation

4. Monitoring fluid intake and output

The correct answer is: Monitoring fluid intake and output

Monitoring fluid intake and output is crucial for a patient with congestive heart failure (CHF) because it provides vital information about the patient's fluid balance and overall cardiac function. In CHF, the heart's ability to pump blood effectively is compromised, which can lead to fluid accumulation in the body. By keeping a close eye on both fluid intake (the amount of fluids the patient consumes) and fluid output (the amount of fluids the patient excretes through urine, sweat, etc.), nurses can identify early signs of fluid overload or dehydration. A positive fluid balance may indicate worsening heart failure or other complications, necessitating timely intervention to prevent further deterioration. This intervention aids in managing the patient's symptoms, assessing treatment efficacy, and guiding adjustments in medication or dietary restrictions, particularly regarding sodium and fluid intake. Overall, effective monitoring of fluid balance is integral to optimizing the management and care of patients with CHF.