Level: Foundational
Difficulty: Easy
Subtopic: Cardiac disorders
NCLEX: A client with heart failure has crackles bilaterally, 2+ pitting edema, and reports waking up short of breath. Wh…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A client with heart failure has crackles bilaterally, 2+ pitting edema, and reports waking up short of breath. Which intervention is the priority?
Question
A. Position the client upright, assess oxygenation, and administer prescribed diuretic/oxygen per protocol.
B. Encourage 2 L of oral fluid intake to prevent dehydration.
C. Ambulate the client in the hallway before reassessing lungs.
D. Document findings and reassess next shift.
B. Encourage 2 L of oral fluid intake to prevent dehydration.
C. Ambulate the client in the hallway before reassessing lungs.
D. Document findings and reassess next shift.
Rationale
Correct answer: A. Position the client upright, assess oxygenation, and administer prescribed diuretic/oxygen per protocol.
Rationale: Pulmonary edema and fluid overload require upright positioning, oxygenation, and diuresis per provider orders—not fluid loading or delayed care.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Pulmonary edema and fluid overload require upright positioning, oxygenation, and diuresis per provider orders—not fluid loading or delayed care.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.