# Situation: A 72-year-old woman with heart failure is going home after treatment for fluid overload. She takes furosemide 40 mg every morning and lisinopril 10 mg daily and has been told to follow a low-sodium diet. She lives with her daughter, who cooks for the family. She reads well and records her blood pressure readings in a notebook. The nurse teaches her to weigh herself every morning and to call the heart failure clinic if her weight rises by 1 kg or more in 1 day or by 2 kg or more in 1 week. At her follow-up visit, her weight log shows: Sunday 58.0 kg Monday 57.8 kg Tuesday 58.1 kg Wednesday 58.2 kg Thursday 59.4 kg Friday 59.3 kg Saturday 59.2 kg Based on this teaching, when should she have called the clinic?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629750  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 72-year-old woman with heart failure is going home after treatment for fluid overload. She takes furosemide 40 mg every morning and lisinopril 10 mg daily and has been told to follow a low-sodium diet. She lives with her daughter, who cooks for the family. She reads well and records her blood pressure readings in a notebook.

The nurse teaches her to weigh herself every morning and to call the heart failure clinic if her weight rises by 1 kg or more in 1 day or by 2 kg or more in 1 week. At her follow-up visit, her weight log shows:
Sunday 58.0 kg
Monday 57.8 kg
Tuesday 58.1 kg
Wednesday 58.2 kg
Thursday 59.4 kg
Friday 59.3 kg
Saturday 59.2 kg
Based on this teaching, when should she have called the clinic?

## 보기

1. No call was needed, as her weekly gain was under 2 kg
2. Friday, after a second weighing confirmed the gain
3. Thursday, as soon as she saw that morning's weight **✔ 정답**
4. Wednesday, after her weight had risen 2 days in a row

**정답: 3**

## 해설

She was taught to report a gain of 1 kg or more in 1 day or 2 kg or more in 1 week. From Wednesday to Thursday her weight rose 1.2 kg (58.2 to 59.4 kg), which meets the 1-day rule even though her gain for the whole week stayed below 2 kg. A sudden gain reflects fluid retention and should be reported the same day, not after it is confirmed.

## 심화 해설

Applying the reporting rule day by day
She was taught two thresholds: call the clinic if her weight rises by 1 kg or more in 1 day or by 2 kg or more in 1 week. Reading the log one day at a time, the changes are Sunday to Monday -0.2 kg, Monday to Tuesday +0.3 kg, Tuesday to Wednesday +0.1 kg, and Wednesday to Thursday +1.2 kg (58.2 to 59.4 kg). The Thursday reading meets the 1-day rule, so she should have called that same morning as soon as she saw the weight. Friday and Saturday show a slight fall, but that does not undo the trigger that was already met.

| Day | Weight (kg) | Change from the day before |
| --- | --- | --- |
| Sunday | 58.0 | Baseline |
| Monday | 57.8 | -0.2 |
| Tuesday | 58.1 | +0.3 |
| Wednesday | 58.2 | +0.1 |
| Thursday | 59.4 | +1.2 (meets the 1-day rule) |
| Friday | 59.3 | -0.1 |
| Saturday | 59.2 | -0.1 |

Why a sudden gain matters in heart failure
In heart failure, a rapid weight gain over a day or two is almost always fluid retention, not fat or muscle. One liter of retained fluid weighs about 1 kg, so a 1.2 kg overnight rise means roughly that much fluid has accumulated. Weight usually rises before breathlessness, orthopnea, or edema become obvious, which is why daily morning weights are the most sensitive home tool for catching early decompensation. Reporting promptly allows the clinic to adjust her furosemide and review sodium intake before she needs readmission.

Why the other choices are wrong
Saying no call was needed applies only the weekly rule; her largest gain within the week was 1.6 kg (57.8 to 59.4 kg), below 2 kg, but the two rules are independent and meeting either one is enough. Waiting for Friday's second weighing to confirm the gain delays treatment, because the rule calls for reporting as soon as the gain is seen. Calling on Wednesday because the weight had risen two days in a row treats a trend as a trigger, but the rises of 0.3 and 0.1 kg meet neither threshold.

Watch out! Exam items like this one hide the answer in the arithmetic. Calculate each day-to-day change and the change within the week separately, then check each against its own threshold.

Exam takeaway
Key point! Daily weights are taken every morning after voiding and before breakfast, on the same scale and in similar clothing. A gain of 1 kg or more in a day or 2 kg or more in a week is reported the same day, without waiting for confirmation. Teaching the daughter who cooks about low-sodium meals supports the plan, but the weight rule is what triggers the call.

## 임상 시나리오

Daily Weight Reporting RuleHome monitoring in heart failure
Report a gain of 1 kg or more in 1 day or 2 kg or more in 1 week. The two rules are separate; meeting either one is enough to call the heart failure clinic.

A rise from 58.2 to 59.4 kg overnight is 1.2 kg, about 1.2 L of retained fluid. Weight gain often appears before breathlessness or edema.

Weigh every morning after voiding and before breakfast, on the same scale and in similar clothing, and record each value in the notebook.

CautionDo not wait for a second weighing to confirm a sudden gain; the call is made as soon as the threshold is met.

## 핵심 개념

- **Daily weight** — A morning weight taken under the same conditions each day to detect fluid retention early.
- **Fluid retention** — Accumulation of excess body water; in heart failure about 1 kg of sudden weight gain equals about 1 L of fluid.
- **Furosemide** — A loop diuretic that removes excess fluid by increasing sodium and water excretion in the kidney.
- **Decompensated heart failure** — Worsening heart failure with fluid overload, causing breathlessness, edema, and weight gain.

## 같은 주제 문제

- [Situation: A 34-year-old woman is being discharged from the medical ward after treatment f…](https://mymerci.kr/pages/nclex_q.php?qn_id=629746)
- [Situation: A 34-year-old woman is being discharged from the medical ward after treatment f…](https://mymerci.kr/pages/nclex_q.php?qn_id=629747)
- [Situation: A 34-year-old woman is being discharged from the medical ward after treatment f…](https://mymerci.kr/pages/nclex_q.php?qn_id=629748)
- [Situation: A 34-year-old woman is being discharged from the medical ward after treatment f…](https://mymerci.kr/pages/nclex_q.php?qn_id=629749)
- [Situation: A 72-year-old woman with heart failure is going home after treatment for fluid …](https://mymerci.kr/pages/nclex_q.php?qn_id=629751)
- [Situation: A 72-year-old woman with heart failure is going home after treatment for fluid …](https://mymerci.kr/pages/nclex_q.php?qn_id=629752)
- [Situation: A 60-year-old man had an abdominoperineal resection with a permanent descending…](https://mymerci.kr/pages/nclex_q.php?qn_id=629753)
- [Situation: A 60-year-old man had an abdominoperineal resection with a permanent descending…](https://mymerci.kr/pages/nclex_q.php?qn_id=629754)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._