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An elderly client is being monitored for evidence of congestive heart failure. To detect early signs of heart failure, the nurse would instruct the certified nursing attendant (CNA) to do which of the following during care of the patient?
A. Observe electrocardiogram reading and report deviations to the nurse
B. Assist the client with ambulation three times during the shift
C. Monitor vital signs Q 15 minutes and report each reading to the nurse
D. Accurately weigh the patient, report finding to nurse, and chart finding.
Answer: D, Accurately weigh the patient, and report and record the readings.
Rationale: Due to fluid accumulation, an expanded blood volume can result when the heart fails. Body weight is a sensitive indicator of water and sodium retention, which will manifest itself with edema, dyspnea - especially nocturnal - and pedal edema. It is not within the role of the CNA to monitor ECG readings, and ambulation is not an assessment. Vital signs every 15 minute are not necessary for this level of patient care.