# A nurse is teaching a 72-year-old client with chronic heart failure (reduced ejection fraction) about early warning signs of decompensation that should prompt a call to the provider. Which findings should the nurse instruct the client to report immediately? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=366202&lang=en > language: en > subject: Medical Emergencies > category: PA ## Question A nurse is teaching a 72-year-old client with chronic heart failure (reduced ejection fraction) about early warning signs of decompensation that should prompt a call to the provider. Which findings should the nurse instruct the client to report immediately? Select all that apply. 1 Occasional use of acetaminophen for chronic knee osteoarthritis, as prescribed, without any new or worsening symptoms 2 A resting heart rate of 50 to 60 beats per minute in a client on a beta-blocker, with no lightheadedness or syncope 3 New or worsening shortness of breath at rest, when lying flat (orthopnea), or waking from sleep with sudden breathlessness (paroxysmal nocturnal dyspnea) 4 A home blood pressure reading of 118/72 mm Hg, consistent with recent readings, without any new symptoms of dizziness 5 A sudden weight gain of 2 to 3 pounds (about 1 to 1.5 kg) in a single day, or 5 pounds (about 2.3 kg) in a week 6 Mild fatigue at the end of the day that resolves after a short rest period, with no limitation in usual activities ## Explanation New or worsening dyspnea at rest, orthopnea, or paroxysmal nocturnal dyspnea suggests pulmonary congestion and requires prompt evaluation (Choice 3). A rapid weight gain of 2 to 3 lb in one day or 5 lb in one week indicates fluid retention and should also be reported promptly (Choice 5). Prescribed acetaminophen without new symptoms is not an early heart-failure warning sign (Choice 1). An asymptomatic resting heart rate of 50 to 60 may be expected with a beta-blocker (Choice 2). A stable blood pressure of 118/72 without dizziness is not concerning (Choice 4), and mild fatigue that resolves with rest without limiting usual activity is not decompensation by itself (Choice 6). ## In-depth explanation CHF Early Decompensation — Self-Monitoring 1. Daily morning weight after voiding, before breakfast — same scale, same clothing 2. Dyspnea triad: at rest, orthopnea (need extra pillows), PND (waking up gasping) 3. Edema: ankles, abdomen new or worsening 4. Activity intolerance: less tolerance than baseline 5. Cough: dry, persistent, especially at night Memory Tip — "FACES of CHF" Fatigue (new), Activity limitation, Chest congestion / Cough, Edema, Shortness of breath. Action Threshold Weight gain 2 lb/day OR 5 lb/week → call provider same day. Resting dyspnea or PND → call same day; if severe, call 911. Caution Avoid NSAIDs (fluid retention) and high-sodium foods (>2 g/day target). Take diuretic in morning; do not skip even if asymptomatic. ## Clinical scenario Scenario 72 y.o., chronic HFrEF (EF 30%). Stable on carvedilol, lisinopril, furosemide, spironolactone. Clinic teaching today on home monitoring and when to call. Discharge Tools - Bathroom scale, daily weight log - Home BP cuff - Sodium tracker (target < 2 g/day) - Pillbox with morning diuretic dose - Action plan card (green/yellow/red zones) Yellow Zone (call same day) - Weight ↑ 2-3 lb/day OR 5 lb/week - New or worse dyspnea, orthopnea, PND - New ankle/abdominal swelling - New persistent cough Red Zone (call 911) - Severe SOB, cannot speak in full sentences - Chest pain - Confusion - Pink frothy sputum ## Key concepts - **Daily weight monitoring** — The single most sensitive early indicator of fluid retention in HF. Weigh at the same time each morning after voiding, before breakfast, in similar clothing, on the same scale. A gain of 2-3 lb in 24 hours or 5 lb in a week signals decompensation and requires provider contact. - **Orthopnea and paroxysmal nocturnal dyspnea (PND)** — Orthopnea = dyspnea when lying flat, relieved by sitting up; client typically uses extra pillows. PND = sudden waking 1-3 hours into sleep with severe dyspnea, lasts 15-30 min after sitting up. Both reflect left-sided HF pulmonary congestion and require same-day evaluation. - **HF self-management action plan** — Three-zone tool: green (stable, continue plan), yellow (early decompensation, call provider same day), red (severe symptoms, call 911). 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